Wiki Question from a Legal/Compliance Perspective

[drashby]

We recently went to a new EMR and integrated our hospital and hospital owned clinics. The hospital uses the encoder and all services drop into a queue for the coders to assign ICD/CPT/HCPCS and save as final. Until saved as final encounters remain in a "draft" status. Once finalized the encounter is released for billing. The clinics bypass this step because the providers are assigning their codes through order entry. Therefore, the status never changes from "draft" to "final".

The question posed from Senior Leadership, "what I am asking is that the electronic record shows that the diagnosis is "draft". If we need to present this information in some format, do we have an issue because it is not marked "final" - (read "complete")." The concern is that the EMR does not state final and therefore could cause a legal issue of some sort.

Appreciate any feedback you could provide.

Thanks- Debby

 

[JenniferB7]

That would be a question for your attorney, but common sense tells me that would be an issue in a court of law. If I was an attorney going after a physician, I would certainly use the fact that a note is "draft" and not "final" as part of my argument and as a justification that the physician did not properly review or finalize his/her documentation.