Awareness : OBC Tips

Payors Are Watching Electronic Medical Record (EMR) Documentation

Once you sign your note, You Are Responsible For Its Content.

  • Every exam component . . .
  • Every time you copy forward Family/Social History . . .
  • Every HPI and ROS item you document means You Performed Them On That Visit.

If you document something you did not do You Are Putting Yourself And The Institution At Great Risk!

  • Copy/Paste can be a valuable tool for efficiency when used correctly
  • There are major Compliance risks when used inappropriately, including potential fraud and abuse allegations, denial of hospital days, and adverse patient outcomes
  • Make sure your note reflects the reality and accuracy of the service each day