Wiki Pre-Charting

[mvccoding@metroveincenters.com]

I am having a hard time finding any concrete answers. I have some providers who want to start their charting the night before for the next day, this would include opening the correct notes and prepping for that day the day prior. Right now, our EMR will not allow any future dates. I'm taking that as a sign that it shouldn't be done but the research I've conducted I cannot find anything from AMA, CMS, or other regulatory bodies that speak to this. Can anyone clarify if pre-charting is not compliant or just frowned upon?

 

[pedscoder21]

We discourage pre-charting at our organization. Pre-charting has lead to providers documenting information that is unobtainable until the patient is seen (e.g., "patient presents today feeling well."). We have seen pre-charting performed and then the patient doesn't show up, and then the pre-charted note is permanent in the record (and sometimes, the provider has accidentally billed for the service). It's frowned upon.

 

[sls314]

Also, remember that with time-based billing, only the total time spent on the date of the encounter can be counted. Any of that pre-charting time the night before could not be used towards the E/M level for the encounter.

 

[csperoni]

Agree with both above. It's certainly less than ideal for the potential errors, and the time spent doing those activities cannot be counted since it is on a different day than the visit. However, I have never seen anything "prohibiting" it. If it is going to be done against advice, the clinicians must be extra cautious about corrections, updates, and additional information and ensuring the patient was actually seen before signing any records.

 

[amyjph]

I think it depends on what the exact meaning of "pre-charting" is to the provider or practice. However, agree with above, this is fraught with risk and a very bad idea. If the EMR/EHR puts time stamps on any of it, auditors would have a field day. There is a reason the EMR/EHR will not allow it. If I was in compliance at the practice, I would strongly advise never to do it.
What you are opening the door to is cloning, note bloat, and carry-forward. What would be "pre-charted"? How can a provider know what to chart without seeing the patient day-of?

https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/certmedrecdoc-factsheet-icn909160.pdf

https://www.cms.gov/mln905364-complying-with-medicare-signature-requirements

Old dates but still true: https://www.cms.gov/files/document/ehrdocumentationfs062816pdf https://www.cms.gov/files/document/ehrcompliancefs062816pdf

https://www.cms.gov/medicare/medicaid-coordination/states/toolkits-for-providers#documentation-matters-toolkit

https://www.cms.gov/medicare-medicaid-coordination/fraud-prevention/medicaid-integrity-education/downloads/docmatters-medicalprof-factsheet.pdf

"Electronic health records (EHRs) require similar methods, but the unique nature of an EHR requires extra precautions. 1. Make sure auto-fill and keyword features are turned off. Watch for “cloned” notes—notes that appear identical for different visits; these may not reflect the uniqueness of the encounter or the patient’s description of their chief complaint. 2. Make sure all notes have a date and time stamp, even when updating patient history and life events. Separate notes entered at different times by paragraph returns or other clear punctuation or spacing. 3. Make sure any edits to the patient’s record are also initialed or identified with the person making the edit."

https://www.cms.gov/medicare-medicaid-coordination/fraud-prevention/medicaid-integrity-education/downloads/docmatters-ehr-providerfactsheet.pdf

See page 2 of the link above
Snippet: "2. Author Identification—Different providers may add information to the same progress note. When this occurs, each provider should be allowed to sign his or her entry, allowing verification of the amount of work performed and which provider performed the work. [14] 3. Altering Entry Dates—Be sure the EHR system has the capability to identify changes to an original entry, such as “addendums, corrections, deletions, and patient amendments.” When making changes, the date, the time, the author making the change, and the reason for the change should be included. Some systems automatically assign the date an entry was made. Others allow authorized users to change the entry date to the date of the visit or service. Some systems allow providers to make undated amendments without noting that an original entry was changed. [15] If there is no date and time on the original entry or subsequent amendments, providers cannot determine the order of events, which can impact the quality of patient care provided.