The OIG, CMS and private payers have warned clinicians against producing identical notes using their EHRs. And yet, we want physicians to use the features of these programs to more easily document their services. Often the results are lowered productivity and clinical notes that don’t provide meaningful clinical data and look identical to one another. Medical practices need policies to guide clinicians and auditors with the Documentation Guidelines and guidance from payers in mind.
- Define a policy for copying/pre-populating from previous notes
- Identify audit strategies for new and established patient services
- List three strategies for engaging physician leadership