Outpatient Facility Coding Alert - 2007 Issue 7
ELECTRONIC HEALTH RECORDS: Beware--Too Much Cutting And Pasting Could Wound You
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Article Overview
This article covers draft guidance for electronic health record systems that focuses on fraud prevention, audit readiness, documentation integrity, and security controls. It is relevant to clinicians, compliance staff, coders, auditors, and EHR vendors who need to understand how documentation practices may be evaluated under emerging standards. The discussion addresses broad areas such as copied documentation, audit functions, user verification, patient access, and linking claims to supporting records.
Why This Topic Matters
The topic matters because EHR design and documentation workflow can affect audit exposure, compliance oversight, and the reliability of support for billed services.
Article Sections
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Draft anti-fraud standards for EHRs
Introduces the draft standards and the organizations involved in developing them. Summarizes the main compliance and documentation issues the guidance is intended to address.
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Documentation integrity and audit controls
Covers proposed system features related to copied content, audit trails, record review, and traceability of visit notes. Also addresses access controls and patient involvement in record review.
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Next steps for finalization and adoption
Describes the process for finalizing the standards and how they may be incorporated into EHR certification activities. Notes the role of participating organizations and review by members.
What You Will Learn
- The general purpose of draft EHR anti-fraud standards
- How EHR design can affect documentation oversight and audit readiness
- What broad categories of security and traceability features the standards discuss
- How certification-related organizations may be involved in adopting the guidance
Who Should Read This
- Coders
- Compliance professionals
- Auditors
- Physicians
- EHR vendors
- Practice managers
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