Compliance Challenges with Electronic Health Records  

Category: Coding

By: Julie Sheppard, BSN, JD, CHC

There are many compliance challenges that result from the use of electronic health records. Some of the challenges are obvious and well known, such as the need to protect patient privacy and avoid inadvertent disclosure of PHI to improper parties. Unfortunately, some risks are not as clear and require extra attention. For instance, providers may have a false sense of security with EHR generated notes vs. handwritten notes and develop unnecessary risk in billing and coding.

Documentation created through EHR should be carefully considered. Cloning, cutting and pasting, and templates are reason for caution. EHR- generated notes may become too lengthy and not contain pertinent information relative to the date of service.

There are pitfalls that arise in coding, particularly with established patients in Evaluation and Management (E...