Documentation & EMR Guidelines

Columbia Doctors policy on the use of the Electronic Medical Record

Purpose

The purpose of this policy and procedure is to establish the requirements regarding electronic documentation in our ambulatory electronic health record (EMR) called EPIC.

Following the principles below will help to ensure accurate and effective documentation practices that serve our patients well, enable robust communication and care coordination and are considered best practices for risk management purposes.

Background

Creating an electronic medical record that facilitates excellence in patient care, meets regulatory requirements (such as billing compliance) and constitutes an accurate legal record for risk management purposes requires attention and vigilance. Legal, ethical and billing compliance principles that apply to electronic documentation are no different than those governing traditional handwritten notes. However, there are two fundamental differences between the paper record and the EHR. First, EHRs have built in “support tools” like Copy Forward that can be simultaneously helpful and potentially problematic. Second, EHRs provide audit logs that can support review of the record.

Policy & Procedure

  1. Effective Clinical Communication.
  2. Notes should be concise, accurate, well-formed and easy to read.
  3. Notes should emphasize what took place on the day of service.
  4. Special emphasis should be placed on the Discussion and Plan portions of the note to clearly communicate the clinical reasoning behind the plan for diagnostic work up or pros and cons of particular treatment decisions.

Use of Electronic Documentation Support Tools (e.g. Copy/Paste, Copy Forward):

  1. “Copy and Paste” and “Copy Forward” should be used with extreme care.
  2. Wholesale copying and pasting text without attribution from another provider (most egregiously, another’s History of Present Illness (HPI), but including, for example, a radiology report without attribution) must be avoided.
  3. It is acceptable to copy forward lists (e.g. problems, allergies, medications, social history items, health maintenance, immunizations) as long as they are always reviewed and updated and do not clutter the note. Bringing forward previous history critical to longitudinal care is encouraged, so long as it’s always reviewed and updated. To copy forward other elements of history, physical examination or formulations should be avoided, as errors in editing may jeopardize the credibility of the entire note.
  4. Copying and pasting wholesale laboratory and radiology reports should be avoided. Important results should be noted, interpreted, and any actions taken in relation to results should be documented. Wholesale importation of information readily available elsewhere in the EHR creates unnecessary clutter, and may adversely affect readability.
  5. The bill submitted for each service should reflect what was done during that specific service.

Timeliness

  1. Timely completion of medical record entries is required. Attending linkage/attestation statements should be done within 24 hours of the resident note to which it is linked.
  2. Practitioners should sign and finalize their notes within 24 hours of the service rendered. Transcriptions from dictations should be reviewed within 48 hours, followed by making the note “final.” Notes finalized (i.e. completed) after 48 hours from the service rendered may be considered non-compliant.
  3. No charges should be submitted/billed without a signed note for the care that is being billed.
  4. Practitioners should review their EPIC work queue for timely completion of “Sign Note” tasks.

Supervision & Ownership of Notes:

  1. Practitioners are required to author their own notes. Multiple practitioners may co-author a given note in EPIC if they are jointly providing a given service, but the responsible attending physician must review, contribute his or her own content, and sign as the ultimate “owner” of each note for that attending physician’s patients.
  2. Practitioners must not share passwords and nor edit or otherwise change the content of another practitioner’s EHR note if not involved in providing a particular service.
  3. Attestation statements for some services and procedures require specific statements regarding attending presence or involvement. Physician extenders must be supervised. Documentation and any billing by physician extenders should be under the rules of “incident to” billing or under their own billing numbers. Practitioners should check with their billing compliance officer if they are not sure what is required.
  4. Once a note is finalized, an addendum can be added to document additional clinical information, or further clarification of services rendered during the visit as appropriate.

Security & Privacy:

  1. Notes must only be entered in the EHR. Other electronic outlets (e.g. Google Documents, Gmail, Evernote and other Cloud services) are not secure and do not protect patient privacy. They must never be used to author clinical notes. To do so violates HIPAA and other privacy regulations.

Compliance and Auditing:

  1. All Health Record documentation can be read by others and audited, and should be written accordingly.
     

 

 

 

 

Office for Billing Compliance
Policy#: 10031
Original Date of Issue: 1996
Revised: 3/22/2023
Reviewed: 3/1/2024