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The Electronic Health Record & use of the 'copy forward' function
1. The Electronic Health Record & use of the
'copy forward' function
Dos and Don’ts of ‘copy forward’ Functionality in Electronic Health
Records
Presenter
John E. Steiner
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http://www.audioeducator.com/medical-coding-billing/copy-forward-
functionality-dos-donts-11-20-2014.html
Editor's Notes
The objectives of this session are as follows: (read 1 – 4 off of slide)
Creating an electronic health record that facilitates excellence in patient care, meets requirements for billing, and constitutes a suitable legal record for your protection, requires attention and vigilance. The ethical and legal principles that apply to electronic documentation are no different from those governing traditional handwritten notes. However, there are two fundamental differences between the paper record and the electronic health record (EHR). First, EHR’s have built in “support tools” like copy-forward and refer to that can be simultaneously helpful and create issues if misused. Second, EHR’s have audit logs that track every keystroke.
CTCA is unique in that our patients are examined by several billable providers on the same day. This model of care increases:
the importance of compliant documentation that tells the patient story,
quickly provides relevant information to the succeeding provider, and
supports billing.
Often CTCA patients are seen by the Intake doctor, the medical oncologist, the naturopath, and a radiologist all on the same day, as well as several non-billable providers. Clinical documentation by each provider must support medical necessity for that specific encounter, and avoid looking cloned.
We will talk about the different functions you can use within the E H R to accomplish this.
I would also encourage you to complete the Computer-Based Learning (CBL) courses we created where you can earn CME.
The guidelines that were in place for paper records have not changed with implementation of the electronic version.
** now, read the slide. When copy forward includes notes from previous visits in a current note, it is difficult to determine what was actually performed as part of the encounter for that date of service.