tci Part B Insider - 2006 Issue 11

ELECTRONIC HEALTH RECORDS: Beware The Attack Of The Cloned Documentation

Most EHR systems don't let you track who made changesThe most common electronic health records (EHR) systems fail to provide a good audit trail that would allow you to figure out who changed what.Problems: Many EHR systems allow "canned" documentation that a provider cuts and pastes from a previous visit or a template, according to a study of roughly 30 products by consultants Pati Trites and Reed Geltzer with Advocates for Documentation Integrity and Compliance in Augusta, MI. And with many systems, you can't even find a record showing that the provider used "canned" documentation at all. Many...

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