THE BELL CURVES HAVE SHIFTED  

Category: Practice Management

With the introduction and now continued implementation of the Electronic Medical Record (EMR), it's more important than ever to make certain that the documentation supports the individual level of service for each patient being seen.  With the creation of templates, smart phrases, easy text, etc., the clinicians are able to document more compliantly to the E/M documentation guidelines without taking medical necessity into account. This is troubling to the payers and should also be to the companies creating the records as well as the providers using them.

Educating everyone within the healthcare stream is vital! The technicians and programmers need to understand why the documentation is so important and how they should be incorporated into the electronic note. It is also imperative to have this understanding so that records can be created, stored, and maintained appropriately. Ed...