Must Know
Secrets for Easier EHR
Documentation
Presentation
#CureMDWebinar

Presenter
Key Technical Services Account
Manager, CureMD
Joe Martin

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Let Me Introduce You to…

An unhappy EHR user
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My EHR has slowed me down
I am seeing less and less patients
My Practice took a revenue hit since
I went electronic and there is no recovery in sight
ICD-10 is coming. If my EHR is the only savior
I have; I should Kiss my Practice Good Bye
+ +
+
ICD
10
Coming

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Do you have the right system?
Wrong System
Generic
No One-On-One Training
In-Built Provider Notes
Built for Billing Purposes mostly
No Efficiency Reporting
Built for a non-familiar Platform
Support is negligible
Specialty Based
Proper Training and Implementation
Customized Provider Notes
Built for Patient Care
Practice Productivity Insights
Built for a Platform you’re familiar with
Support is available when needed
Right System

Polling Question
Q1. Which category do you fall in?
a. Right system
b. Wrong system

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If you have the right system and are still spending more than 10-15
minutes on a simple patient visit. You need an
EHR Documentation Fix!

Why Bother?
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Physician documentation is Important!
Inform subsequent care
Inform current care (“writing-as-thinking”)
Legal purposes
Gets You Paid !- ICD-10 Medical NecessityICD
10
Coming
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PROBLEM ?
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Our World Pre-EHRs
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“If it’s not documented,
it didn’t happen?”

The Paper Work Burden
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Care setting Ratio of patient care
to paper
Every hour of patient
care requires
Emergency department care
Surgery and inpatient acute care
Skilled nursing care
Home health care
1.0
1.0
1.0
0.6
1.0
0.5
1.0
0.8
1 Hour of paperwork
36 Minutes of paperwork
30 Minutes of paperwork
48 Minutes of paperwork
What does it Mean?

Here comes the New World
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“If it’s documented,
was it done?”

The Murky World of Audits
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OIG will be reviewing multiple E/M services for the same provider and beneficiaries to
identify electronic health record documentation practices associated with potentially
improper payments
The results of a recent CMS study suggest the OIG will find plenty of E/M documentation
problems among EHR users
Highest failure rate
Each physician pays back $ 150,000
lowest failure rate=
Each physician pays back $50,000

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7 Commandments for creating the Perfect Provider Note
Save Time while Staying clear of Compliance Landmines

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Commandment Number 1
The‘Dead Doc’rule
If something happens to you, can someone else
know what you did by looking at your notes?

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Commandment Number 2
Do not Compromise
On
Documentation Integrity
Every exam component. .Every time you copy
forward Family/Social History . . .Every HPI and
ROS item you document means
YOU PERFORMED THEM ON THAT VISIT . . .
If you document something you did not do . . .
YOU ARE PUTTING YOURSELF AND THE
INSTITUTION AT GREAT RISK!

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The other day at work I was taking care of a patient that was in an MVC. She was in spinal precautions and
complained of neck and leg pain. Our ED Physician came in and did his exam from the doorway holding his
Tablet PC, marking off items into the Electronic T-sheet while he asked a few basic questions. He was in and out
in less than a minute. Out of curiosity, I reviewed his documentation and not surprisingly there was a
comprehensive assessment documented.
Abdominal findings, lungs sounds, heart sounds, pupil and ocular movements, euro exam, all beautifully
documented in a long paragraph and all normal. Not bad for an exam conducted from the doorway. The same
physician had the same general exam pattern for most of his patients and the same comprehensive
documentation of his exams.
“
”

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Commandment Number 3
Which EHR Entry Modality to use?
No Hard and Fast Rule

Documentation Methods Compared
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Description Structured templates are partially filled-in notes created in advance for the most common cases
seen by a clinic, department, and/or doctor. Such templates allow clinicians to create a note that
not only serves as the medical record, but also stores the data as structured vocabulary, which can
drive clinical decision-support functions (such as alerts and/or treatment suggestions based on
established care guidelines).
Advantages Structured templates ease note-taking by presenting a draft to the clinician, who then modifies
portions of the note to reflect the current patient’s condition. Depending on the values and
content of data fields, additional forms may pop up (as determined by care guidelines of the health
center) to ensure a thorough exam. For example, a symptom of chest pain could prompt questions
about exertion, family history of heart disease, and history of smoking. Standardized
templates allow for uniformity in data capture and in the standards of care provided. Over time,
templates improve
Disadvantages Physicians often complain that notes from structured templates are difficult to read as a narrative
of the patient’s condition, as they appear more as lists than as prose. A “chart by exception”
approach, where all findings are prepopulated as negative unless the provider explicitly checks and
documents a positive finding, brings its own problem of seeming to provide data the clinician may
not have actually captured. Considerable preparation is required to develop structured templates
that present enough structured vocabulary to cover the types of patients and conditions seen in
the practice, but not so much that clinicians are hobbled, or that the data cannot be classified.
Structured
Method Structured Templates
Structured Templates

Documentation Methods Compared
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Structured templates work well for clinical scenarios with an isolated problem that fits a clear
framework with a limited number of easily predictable variations. For example, a template for a
patient with a chief complaint of headache can present to the provider a set of signs, symptoms,
and physical exam findings that should be checked and listed as either present or absent. Similarly,
structured templates work well for acute episodes of care for which there are clear
clinical guidelines, for specialty care in which the range of diagnoses and conditions is limited, and
for predictable well care checkups or OB cases that follow a regular schedule.
Method Structured Templates
Method Radio Buttons, Drop-down Lists, Check Boxes
Best Suited For
These data entry methods provide clinicians with a variety of ways to enter structured data. A
drop-down list presents suitable alternatives to clinicians and usually offers menu options based
on data entered in an earlier part of the
note. Radio buttons help enter mutually exclusive data options such as gender or yes/no answers.
Check boxes help in maintaining and tracking quality of care by signaling exams performed or
questions asked. Each entry selected is encoded and stored as a discrete data element that can be
aggregated or can drive other clinical protocols and decision support. Check boxes, drop-down
menus, and radio buttons can also be embedded within sections of templates.
Description
These devices allow for rapid point-and-click selection of structured data elements and are
especially useful when, through logic imbedded in the EHR, only the appropriate subset of
available data selections is displayed. For example, only medications commonly associated with
diabetes would be displayed in a drop-down list for a diabetic patient.
Advantages
Radio Buttons, Drop-down Lists,
Check Boxes

Documentation Methods Compared
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Some providers complain of too much “clicking” and about the inconvenience of moving from
keyboard to mouse to keyboard when documenting their plan of care or clinical note. As with any
structured template, careful thought must be given to the appropriate level of detail for choices in
lists, check boxes, etc. In addition, there has been some concern that not enough research has been
done to determine the optimal spacing between items in a drop-down list to prevent accidental
selection of the wrong data element.t
Method Radio Buttons, Drop-down Lists, Check Boxes
Method Manual Data Entry (Typing, Stylus, Free-Text Templates)
Disadvantages
Radio buttons and check boxes are best suited for yes/no questions such as those about smoking,
drinking, or I.V. drug use. Drop-down lists are appropriate for parts of the clinical note where there
are only a few possible descriptions, and for ruling out symptoms (e.g., no upper respiratory
symptoms, no G.I. symptoms).
Best Suited For
Manual data entry is referred to as free text in EHR parlance and can be accomplished by typing on
the keyboard or, in some applications, by handwriting with a stylus. Free-text templates allow
providers to type in notes in any format.
Description
If the provider is a fast typist, text can be entered quickly and the note will be expressed in the
provider’s preferredstyle of writing. Free-text templates capture notes that can be retrieved
electronically and allow providers to include information that doesn’t have a predetermined place
in structured vocabulary.
Advantages
Manual Data Entry

Documentation Methods Compared
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Free-text templates are not coded or linked, so they will not trigger prompts or additional
information, and they will not show up in searches of linked terms.
Method Manual Data Entry (Typing, Stylus, Free-Text Templates)
Method Voice Dictation, Dictation/Transcription
Disadvantages
Free-text templates work well for capturing additional data or interpretations not covered by
structured vocabulary, such as parts of the note where there is a significant degree of variation
that does not easily lend itself to a predefined template. The History of Present Illness and the Past
Medical History sections are examples.
Best Suited For
Traditional dictation/transcription is streamlined in many modern EHRs by having the provider
dictate directly into a microphone attached to a computer. A .wav or audio file is created and
embedded at the point in the chart that the dictation took place. The .wav file is then sent to a
transcriptionist, typed, and uploaded back into the chart as a freetext note. Voice dictation systems
translate the spoken word directly into written text within the EHR.
Description
Dictation offers the most rapid method for capturing a fully detailed narrative with the least effort
expended.
Advantages
Like free text, dictated information is not structured vocabulary, although recent advances may
lead to the ability to capture certain dictated phrases as encoded data. Current voice dictation
systems must be “trained” to the provider’s voice, accent, common phrases, and medical specialty
terminology.
Advantages
Like free text or manual typing, dictation works well for parts of the note where there is a
significant degree of variation that does not easily lend itself to a pre-defined template.
Best Suited For
Voice Dictation

Polling Question
Q2. Which Entry Modality do you prefer in your EHR ?
a. Free text
b. Drop downs
c. Structured templates
d. A little of everything
e. Transcription services

Best Practice Blended Approach
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Does not disrupt physician workflow
Facilitate better physician adoption
Achieve faster Meaningful Use of the EHR
Benefits

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Commandment Number 4
EHR Documentation
No No’s

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When using EHR’s, here are the primary E/M documentation pitfalls to avoid:
• Templates and billing driving care and charting
• Point-and-click mentality vs. accurate and ethical documentation
• Copy and paste forward
• Charting for services that were not performed: use of default entries
• Documentation cloning
• Negatives listed vs. positives – hard to discern what is wrong with the patient
• Failure to review available information
• Inaccurate charting
• Addendums for increased reimbursement vs. for patient care
• Relative value unit (RVU) – driven care
• Signing of notes without reading them
• EHR revealing bad practice patterns
Watch for EHR E/M Documentation No No’s

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Commandment Number 5
Top Compliance Rules
for an EHR

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Each visit is unique. Cloned documentation is very obvious to auditors. Ensure each record
stands alone and is unique from the previous patient or visit
If you bring a note forward it MUST reflect the activity for the CURRENT VISIT with
appropriate editing
Copy forward HPI, Exam, Vitals and complete Assessment
Copy Paste for Multiple or Complex diagnosis. Dictate notes using software that converts it to
text
Use “Copy Forward” with caution
Do NOT

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Be Cautious with ROS and Exam
Macros, Check‐boxes, or Free Text are safer and more individualized
Read your assessment and plan and ask yourself: “Is the information contained in the history
and examination relevant for the nature of the presenting problem?” If you answer yes then you
have the required information for the problem presented. If the answer is no, remove
unnecessary information that doesn’t have any relevance to the current problem
Be careful with pre‐populated “No"
or “Negative” templates

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Never copy ANYTHING from one patient’s record
into another patient’s note

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Authenticate all documentation and
orders in a timely fashion
48 hours for verbal
orders
30 days for signed
documentation

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Never copy documentation from another provider
without clearly identifying the original author
Can be considered a
false claim
Not always easy to do,
better to avoid

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Student or nurse may start the note
Provider (resident or attending) must document HPI, Exam, Vitals
and Assessment/Plan
Only Past/Family/Social History and Review
of Systems may be used from a medical
student or nurse’s note

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Consider the medical decision making (number of diagnoses, complexity of
data, and risk) to be the most critical elements in code choice. Ensure these
elements are met. The Volume of Documentation should not be the primary
influence upon which a specific level of service is billed. Documentation
should support the level of service

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Commandment Number 6
Adopt an Effective Clinical
Workflow

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Work with cross-trained staff that can handle intake and documentation
Document encounters as much as possible during and immediately after visits, but don't
document more than necessary or spend too much clinical time on complex documentation
Close all patient encounters by the end of the day – this should involve just wrapping up
documentation for more complex encounters
Route documents appropriately and delegate responsibility for document handling effectively
Start on time

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Commandment Number 7
Regular Audit of Provider &
Staff Workflow

Are your providers closing all patient encounters every day?
Are your providers maximizing staff use during intake?
How much time do your providers spend documenting each patient encounter?
How much time do your providers spend on documentation while a patient is in the office and
how much after the patient has left?
Is your practice routing documents appropriately and delegating responsibility for document
handling effectively?
How does your practice stack up against comparable practices across the country?
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For CureMD Customers

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Free iPad app to facilitate multiple platform
usage
DRT Services
Tweaking your Provide Notes for ICD-10
Get in touch with your Implementation
or Support Manager to learn more about
Audit Reports in CureMD

Polling Question
Q3. Which topic would you like us to cover in
our next webinar ?
a. Features in your EHR that faciliate ICD-10
b. Role of Clearing House in ICD-10 Transition
c. Specialty Specific Documentation

Session
QA&

Request a demo to see how CureMD can facilitate
your practice for EHR documentation
Get in touch with our documentation
experts at 718-684-9298
For further inquiries regarding
physician documentation, send us
an email at the healthit@curemd.com
Need Help?

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Thank you!
Look out for our email, containing the webinar
recording and a free eBook
How to Master ICD-10 documentation in 10 days