EMR Clinical Documentation Integrity

CodeCast | Medical Billing and Coding Insights

The Electronic Medical Record (EMR) has many benefits over handwritten entries in a paper chart. EMR entries are always legible, dated, and timed. Patient information can be available at the point of care and remotely.

Some EMR systems include computerized physician order entry and decision-support tools to improve patient care and safety. However, recent audits reflect that CDI can be compromised when copy-paste or pull-forward information is not updated or reviewed.

Terry discusses the importance of the medical record’s integrity and ensuring your providers listen.

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