An electronic medical record is created for every patient who receives treatment, care or services, and is maintained for the primary purpose of providing patient care.
The Medical Record
- The record should contain sufficient information to identify the patient, support the diagnosis, justify treatment and facilitate the continuity of care. Electronic medical records must comply with all HIPAA privacy and security requirements.
- Providers are prohibited from allowing others to use their password or sign their notes. Providers are responsible for the total content of their documentation and that of residents, medical students or any other ancillary personnel under their supervision whether the content is original, copied, pasted, imported or reused.
- The record should clearly identify the author and date of all entries. Entries must be signed/authenticated by the author. Electronic signatures must be password protected and used only by the author. All entries should be signed promptly, allowing a short delay that occurs in the transcription process.
- Providers documenting in the EHR must avoid indiscriminately copying and pasting progress notes and duplicate/redundant information provided in other parts of the EHR. If any information is copied or reused from a prior note, the provider is responsible for its accuracy and medical necessity. The primary purpose of progress notes is to provide an accurate depiction of unique treatment rendered on a specific date of service. Further requirements pertaining to copying and pasting progress notes:
- Copied information must be reconfirmed and revised as necessary to accurately reflect the specific date of service.
- It is not advisable to duplicate information that does not specifically impact a specific date of service.
- Copying of subjective date (i.e. history of present illness and plan of care) is strongly discouraged.
- Copying teaching physician attestations from previous notes is prohibited.
- Information that is copied should not exceed six (6) months from the date of the original note.
- Information copied forward from the providers original notes should be closely examined for accuracy, completeness and relevance.
- Documentation must reference the date of the original note. Example: “Copied from my previous note dated…”
- Providers are responsible for citing and summarizing applicable lab data, pathology, and radiology reports rather than copy such reports in their entirety in the notes.
- Providers are responsible for correcting any errors identified within their own document, via a dated amendment if the note is already signed.
- Providers are required to document in compliance with all federal, state and local laws, as well as with UBMD policy.
Templates
Per CMS Transmittal 455, dated March 15, 2013 use of templates is not prohibited to facilitate recordkeeping, but CMS also does not endorse or approve any particular templates. Providers may choose any template to assist in documenting medical information. However, CMS does discourage the use of templates which provide limited options such as “check boxes” or predefined answers, and/or limited space to enter information, or those designed to gather selected information focused primarily for reimbursement purposes as they often fail to capture sufficient detailed clinical information to demonstrate that all coverage and coding requirements are met, or adequately show that medical necessity criteria for the service are meant.
If using a template, UBMD providers are advised to select one that allows for a full and complete collection of information to demonstrate that the applicable coverage and coding criteria, as well as medical necessity, are met.
Cloning
Documentation is considered cloned when it is worded exactly like, or similar to, previous entries. It can also occur when the documentation is exactly the same from patient to patient. Individualized patient notes for each patient encounter are required. Documentation must reflect the patient condition necessitating treatment, the treatment rendered and, if applicable, the overall progress of the patient to demonstrate medical necessity.
Electronic Health Record Audits
Electronic Health Records should be audited at the practice plan level by each practice plan on a quarterly basis as follows:
- Review of records of VIP patients to make sure records were accessed only by those who took part in the care and treatment of the patient.
- Review of records of UBMD employees who are also practice plan patients to make sure records were accessed only by those who took part in the care and treatment of the patient.
- Randomly select up to fine (5) practice plan employees, and check one day from the previous quarter to make sure their access to records were appropriate.
Any employee found to be inappropriately accessing the EHR of a patient will face disciplinary action up to and including termination.
