Pediatric Coding Alert

When you’re new to electronic medical records (EMRs), it may be tempting to simply trust the vendor on what your template should include—but in reality, the practice should tailor the template to its needs.

"EMRs are definitely useful, but it’s important that the provider be able to select what to include and not necessarily have to click something in order for it to be removed," says Suzan Hauptman, MPM, CPC, CEMC, CEDC, manager of physician compliance auditing with West Penn Allegheny Health System. "It’s one thing to consciously add information—it another thing to have to consciously remove things. That doesn’t happen as often."

To prevent any EMR issues before they happen, you should work with your EMR vendor to ensure that your EMR has what you need on it. Hauptman suggests the following tips that you should follow when creating the EMR:

• Access should be granted to each section based on each staff member’s clinical job and what they are able to document based on the documentation guidelines (for instance, a medical assistant shouldn’t be able to enter exam elements except for vitals).
• No finding (such as "lungs clear to auscultation") should be "hard coded" into the template.
• "All normal" should be defined by the specialty and changeable for each encounter.
• Items from a new patient note should not auto-populate into the established patient note. These should be selected by the clinicians.
• ALL systems should be available for the review of systems. The clinician should pick the ones relevant to the patient/encounter.
• ALL organ systems should be available in the exam. The clinician should document only what was actually done and appropriate for the problem being addressed.
• The decision-making should have enough free text for clinician thoughts and plans.
• Attestation should be available, but must be selected and not "hard coded."
• All areas should be reviewed by a certified coder before putting into production.
• HIPAA issues with regard to who can access what should be addressed.
• Audit trails should clearly indicate who did what and when.