SlideShare a Scribd company logo
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
Follow us :
Objectives
© 2011 Rising Tide 2
1. Review documentation requirements for the Electronic
Health Record (EHR)
2. Explain guidelines for the appropriate use of “copy
forward” in the EHR to ensure medical record integrity
3. Distinguish “copy forward” versus “refer to” functions of
the EHR
4. Risks of using “copy forward” and practices to avoid
Introduction
• Clinicians use the EHR to make decisions about patient
care
• The quality and integrity of EHR content is important
• The EHR is a legal document, it should be compliant
with applicable legal requirements or standards
• The EHR also is a business record
© 2011 Rising Tide 3
Our Patient Empowered Care (PEC)
Model
© 2011 Rising Tide 4
Objective 1: Review documentation
requirements for the Electronic Health
Record (EHR)
1. Notes should be concise, accurate, non-redundant, and easy to
read.
2. Progress notes accurately describe treatment for a specific date of
service.
3. Place emphasis on the “assessment and plan” portion of the
note with the most definitive diagnosis to communicate the clinical
reasoning behind the plan.
4. Each note should stand alone, support medical necessity, and
support the level billed.
5. It is risky to duplicate information that does not specifically impact a
date of service.
© 2011 Rising Tide 5
To see the complete presentation check the
below link:
http://www.audioeducator.com/medical-coding-billing/copy-forward-
functionality-dos-donts-11-20-2014.html

More Related Content

What's hot

Mha690 healthcare confidentiality
Mha690 healthcare confidentialityMha690 healthcare confidentiality
Mha690 healthcare confidentiality
asharp625
 
The Transition from Paper to Electronic Records
The Transition from Paper to Electronic RecordsThe Transition from Paper to Electronic Records
The Transition from Paper to Electronic Records
Matthew Kim
 
4 fundamental-ehr-components-of-increasing-physician-satisfaction-in-your-fac...
4 fundamental-ehr-components-of-increasing-physician-satisfaction-in-your-fac...4 fundamental-ehr-components-of-increasing-physician-satisfaction-in-your-fac...
4 fundamental-ehr-components-of-increasing-physician-satisfaction-in-your-fac...
MEDHOST
 
Pros and cons of ehr
Pros and cons of ehrPros and cons of ehr
Pros and cons of ehr
Nortec Ehr
 
History of electronic health records ppt
History of electronic health records pptHistory of electronic health records ppt
History of electronic health records ppt
cuteus
 
Electronic health records
Electronic health recordsElectronic health records
Electronic health records
Jocelyn Garcia
 
What Are Electronic Health Records (EHRs)?
What Are Electronic Health Records (EHRs)?What Are Electronic Health Records (EHRs)?
What Are Electronic Health Records (EHRs)?
Practice Fusion
 
Electronic medical record for Doctors
Electronic medical record for DoctorsElectronic medical record for Doctors
Electronic medical record for Doctors
Railwire
 
Electronic medical record
Electronic medical recordElectronic medical record
Electronic medical record
Frank James
 
Electronic medical record for patients
Electronic medical record for patientsElectronic medical record for patients
Electronic medical record for patients
Railwire
 
EHR Best Practices
EHR Best PracticesEHR Best Practices
EHR Best Practices
Texas Medical Liability Trust
 
Electronic medical record 25.04.2021
Electronic medical record 25.04.2021Electronic medical record 25.04.2021
Electronic medical record 25.04.2021
Shazia Iqbal
 
Things to Consider Before Buying Cyber Liability Insurance
Things to Consider Before Buying Cyber Liability InsuranceThings to Consider Before Buying Cyber Liability Insurance
Things to Consider Before Buying Cyber Liability Insurance
Texas Medical Liability Trust
 
eHealth - Jim Maclean
eHealth - Jim MacleaneHealth - Jim Maclean
eHealth - Jim Maclean
GHBN
 
Digital Health Records
Digital Health RecordsDigital Health Records
Digital Health Records
Saurav Gupta
 
EHR - Elecronic Health Record
EHR - Elecronic Health RecordEHR - Elecronic Health Record
EHR - Elecronic Health Record
Tabassum Islam Nabanee
 
Scanning, Abstracting, & Adding Medical Records to an EHR
Scanning, Abstracting, & Adding Medical Records to an EHRScanning, Abstracting, & Adding Medical Records to an EHR
Scanning, Abstracting, & Adding Medical Records to an EHR
Record Nations
 
Authentication Best Practices
Authentication Best PracticesAuthentication Best Practices
Authentication Best Practices
Texas Medical Liability Trust
 
Electronic Records
Electronic RecordsElectronic Records
Electronic Records
ThomasSchuler
 
Resume
ResumeResume

What's hot (20)

Mha690 healthcare confidentiality
Mha690 healthcare confidentialityMha690 healthcare confidentiality
Mha690 healthcare confidentiality
 
The Transition from Paper to Electronic Records
The Transition from Paper to Electronic RecordsThe Transition from Paper to Electronic Records
The Transition from Paper to Electronic Records
 
4 fundamental-ehr-components-of-increasing-physician-satisfaction-in-your-fac...
4 fundamental-ehr-components-of-increasing-physician-satisfaction-in-your-fac...4 fundamental-ehr-components-of-increasing-physician-satisfaction-in-your-fac...
4 fundamental-ehr-components-of-increasing-physician-satisfaction-in-your-fac...
 
Pros and cons of ehr
Pros and cons of ehrPros and cons of ehr
Pros and cons of ehr
 
History of electronic health records ppt
History of electronic health records pptHistory of electronic health records ppt
History of electronic health records ppt
 
Electronic health records
Electronic health recordsElectronic health records
Electronic health records
 
What Are Electronic Health Records (EHRs)?
What Are Electronic Health Records (EHRs)?What Are Electronic Health Records (EHRs)?
What Are Electronic Health Records (EHRs)?
 
Electronic medical record for Doctors
Electronic medical record for DoctorsElectronic medical record for Doctors
Electronic medical record for Doctors
 
Electronic medical record
Electronic medical recordElectronic medical record
Electronic medical record
 
Electronic medical record for patients
Electronic medical record for patientsElectronic medical record for patients
Electronic medical record for patients
 
EHR Best Practices
EHR Best PracticesEHR Best Practices
EHR Best Practices
 
Electronic medical record 25.04.2021
Electronic medical record 25.04.2021Electronic medical record 25.04.2021
Electronic medical record 25.04.2021
 
Things to Consider Before Buying Cyber Liability Insurance
Things to Consider Before Buying Cyber Liability InsuranceThings to Consider Before Buying Cyber Liability Insurance
Things to Consider Before Buying Cyber Liability Insurance
 
eHealth - Jim Maclean
eHealth - Jim MacleaneHealth - Jim Maclean
eHealth - Jim Maclean
 
Digital Health Records
Digital Health RecordsDigital Health Records
Digital Health Records
 
EHR - Elecronic Health Record
EHR - Elecronic Health RecordEHR - Elecronic Health Record
EHR - Elecronic Health Record
 
Scanning, Abstracting, & Adding Medical Records to an EHR
Scanning, Abstracting, & Adding Medical Records to an EHRScanning, Abstracting, & Adding Medical Records to an EHR
Scanning, Abstracting, & Adding Medical Records to an EHR
 
Authentication Best Practices
Authentication Best PracticesAuthentication Best Practices
Authentication Best Practices
 
Electronic Records
Electronic RecordsElectronic Records
Electronic Records
 
Resume
ResumeResume
Resume
 

Viewers also liked

Medicare for Eye-care: Coding and Billing Guidelines
Medicare for Eye-care: Coding and Billing GuidelinesMedicare for Eye-care: Coding and Billing Guidelines
Medicare for Eye-care: Coding and Billing Guidelines
AudioEducator
 
Brian manule
Brian manuleBrian manule
Brian manule
brianmanuel
 
Abobe after effects
Abobe after effectsAbobe after effects
Abobe after effects
Emzzino
 
Manual cinema 4 d
Manual cinema 4 dManual cinema 4 d
Manual cinema 4 d
Venise Melo
 
CINEMA 4D COURSE
CINEMA 4D COURSECINEMA 4D COURSE
CINEMA 4D COURSE
George Exarchopoulos
 
Microwave engineering ch2
Microwave engineering ch2Microwave engineering ch2
Microwave engineering ch2
Muhammad Azwir
 
WCM_PRESENTATION_Flange_Management_Rev4
WCM_PRESENTATION_Flange_Management_Rev4WCM_PRESENTATION_Flange_Management_Rev4
WCM_PRESENTATION_Flange_Management_Rev4
Afiman Abdul Rahman
 
Russian economy
Russian economyRussian economy
Russian economy
X-cellon
 
13 Cathodic Protection
13 Cathodic Protection13 Cathodic Protection
13 Cathodic Protection
Worley parsons
 
Patent Basics and Intellectual Property Rights
Patent Basics and Intellectual Property Rights Patent Basics and Intellectual Property Rights
Patent Basics and Intellectual Property Rights
Rahul Dev
 
IPR Protection for Hardware Startups - Patents, Trademarks, Copyrights and De...
IPR Protection for Hardware Startups - Patents, Trademarks, Copyrights and De...IPR Protection for Hardware Startups - Patents, Trademarks, Copyrights and De...
IPR Protection for Hardware Startups - Patents, Trademarks, Copyrights and De...
Rahul Dev
 
Visual effects in power point presentations
Visual effects in power point presentationsVisual effects in power point presentations
Visual effects in power point presentations
Samitha Jayaweera
 
cathodic protection
cathodic protectioncathodic protection
cathodic protection
Abhishek Mishra
 
Vfx PPT
Vfx PPTVfx PPT
Vfx PPT
Mit Shah
 
Chapter 4 software project planning
Chapter 4 software project planningChapter 4 software project planning
Chapter 4 software project planning
Piyush Gogia
 
Maya 2010 Getting Started
Maya 2010 Getting StartedMaya 2010 Getting Started
Maya 2010 Getting Started
codewarrior congrejo
 
Indian patent act
Indian patent actIndian patent act
Indian patent act
Soumya Athira
 
Cathodic protection of reinforced concrete structures
Cathodic protection of reinforced concrete structuresCathodic protection of reinforced concrete structures
Cathodic protection of reinforced concrete structures
Ravi Kumar
 
The patent act
The patent actThe patent act
The patent act
Saurav Ghoshal
 
faradays law and its applications ppt
faradays law and its applications pptfaradays law and its applications ppt
faradays law and its applications ppt
Indira Kundu
 

Viewers also liked (20)

Medicare for Eye-care: Coding and Billing Guidelines
Medicare for Eye-care: Coding and Billing GuidelinesMedicare for Eye-care: Coding and Billing Guidelines
Medicare for Eye-care: Coding and Billing Guidelines
 
Brian manule
Brian manuleBrian manule
Brian manule
 
Abobe after effects
Abobe after effectsAbobe after effects
Abobe after effects
 
Manual cinema 4 d
Manual cinema 4 dManual cinema 4 d
Manual cinema 4 d
 
CINEMA 4D COURSE
CINEMA 4D COURSECINEMA 4D COURSE
CINEMA 4D COURSE
 
Microwave engineering ch2
Microwave engineering ch2Microwave engineering ch2
Microwave engineering ch2
 
WCM_PRESENTATION_Flange_Management_Rev4
WCM_PRESENTATION_Flange_Management_Rev4WCM_PRESENTATION_Flange_Management_Rev4
WCM_PRESENTATION_Flange_Management_Rev4
 
Russian economy
Russian economyRussian economy
Russian economy
 
13 Cathodic Protection
13 Cathodic Protection13 Cathodic Protection
13 Cathodic Protection
 
Patent Basics and Intellectual Property Rights
Patent Basics and Intellectual Property Rights Patent Basics and Intellectual Property Rights
Patent Basics and Intellectual Property Rights
 
IPR Protection for Hardware Startups - Patents, Trademarks, Copyrights and De...
IPR Protection for Hardware Startups - Patents, Trademarks, Copyrights and De...IPR Protection for Hardware Startups - Patents, Trademarks, Copyrights and De...
IPR Protection for Hardware Startups - Patents, Trademarks, Copyrights and De...
 
Visual effects in power point presentations
Visual effects in power point presentationsVisual effects in power point presentations
Visual effects in power point presentations
 
cathodic protection
cathodic protectioncathodic protection
cathodic protection
 
Vfx PPT
Vfx PPTVfx PPT
Vfx PPT
 
Chapter 4 software project planning
Chapter 4 software project planningChapter 4 software project planning
Chapter 4 software project planning
 
Maya 2010 Getting Started
Maya 2010 Getting StartedMaya 2010 Getting Started
Maya 2010 Getting Started
 
Indian patent act
Indian patent actIndian patent act
Indian patent act
 
Cathodic protection of reinforced concrete structures
Cathodic protection of reinforced concrete structuresCathodic protection of reinforced concrete structures
Cathodic protection of reinforced concrete structures
 
The patent act
The patent actThe patent act
The patent act
 
faradays law and its applications ppt
faradays law and its applications pptfaradays law and its applications ppt
faradays law and its applications ppt
 

Similar to The Electronic Health Record & use of the 'copy forward' function

12Epic EMR ImplementationComment by Author 2 Need a
12Epic EMR ImplementationComment by Author 2 Need a 12Epic EMR ImplementationComment by Author 2 Need a
12Epic EMR ImplementationComment by Author 2 Need a
ChantellPantoja184
 
12Epic EMR ImplementationComment by Author 2 Need a
12Epic EMR ImplementationComment by Author 2 Need a 12Epic EMR ImplementationComment by Author 2 Need a
12Epic EMR ImplementationComment by Author 2 Need a
AnastaciaShadelb
 
Electronic Health Records: Implications for IMO State's Healthcare System
Electronic Health Records: Implications for IMO State's Healthcare SystemElectronic Health Records: Implications for IMO State's Healthcare System
Electronic Health Records: Implications for IMO State's Healthcare System
Michael Loechel
 
Key Ways to Improve EHR Usability and Documentation
Key Ways to Improve EHR Usability and DocumentationKey Ways to Improve EHR Usability and Documentation
Key Ways to Improve EHR Usability and Documentation
Medical Transcription Service Company
 
Powerpoint example
Powerpoint examplePowerpoint example
Powerpoint example
Elizabeth Bianchini
 
Electronic Health Record (EHR) Systems: A Revolution in Healthcare.docx
Electronic Health Record (EHR) Systems: A Revolution in Healthcare.docxElectronic Health Record (EHR) Systems: A Revolution in Healthcare.docx
Electronic Health Record (EHR) Systems: A Revolution in Healthcare.docx
doctorsbackoffice4
 
These standards are taken from the HL7 Functional Standards for an.docx
These standards are taken from the HL7 Functional Standards for an.docxThese standards are taken from the HL7 Functional Standards for an.docx
These standards are taken from the HL7 Functional Standards for an.docx
barbaran11
 
How to Complete Patient Documentation on Time
How to Complete Patient Documentation on TimeHow to Complete Patient Documentation on Time
How to Complete Patient Documentation on Time
Medical Transcription Service Company
 
Patient Care Clinical Workflow
Patient Care Clinical Workflow Patient Care Clinical Workflow
Patient Care Clinical Workflow
CMDLMS
 
eHealth for Africa
eHealth for AfricaeHealth for Africa
eHealth for Africa
W John Gachago
 
4.1 Shared care & Electronic Health Record
4.1 Shared care & Electronic Health Record4.1 Shared care & Electronic Health Record
4.1 Shared care & Electronic Health Record
Disha Patel
 
Health Information Technology Workforce Development Program Presentation
Health Information Technology Workforce Development Program PresentationHealth Information Technology Workforce Development Program Presentation
Health Information Technology Workforce Development Program Presentation
BDPA Charlotte - Information Technology Thought Leaders
 
AmericanEHR Partners HIMSS12 Conference HL7 Presentation
AmericanEHR Partners HIMSS12 Conference HL7 PresentationAmericanEHR Partners HIMSS12 Conference HL7 Presentation
AmericanEHR Partners HIMSS12 Conference HL7 Presentation
Cientis Technologies
 
Meaningful Use
Meaningful UseMeaningful Use
ecoa Application
ecoa Applicationecoa Application
ecoa Application
procth2
 
ecoa Application
ecoa Applicationecoa Application
ecoa Application
ProrelixResearch1
 
Transforming Nursing And Healthcare Through Technology.docx
Transforming Nursing And Healthcare Through Technology.docxTransforming Nursing And Healthcare Through Technology.docx
Transforming Nursing And Healthcare Through Technology.docx
write5
 
Introduction to Data Entry and Electronic Health Record.pdf
Introduction to Data Entry and Electronic Health Record.pdfIntroduction to Data Entry and Electronic Health Record.pdf
Introduction to Data Entry and Electronic Health Record.pdf
vishwajeetsingh557119
 
Meaningful Use
Meaningful UseMeaningful Use
1.01 health science career cluster pathways
1.01 health science career cluster pathways1.01 health science career cluster pathways
1.01 health science career cluster pathways
melodiekernahan
 

Similar to The Electronic Health Record & use of the 'copy forward' function (20)

12Epic EMR ImplementationComment by Author 2 Need a
12Epic EMR ImplementationComment by Author 2 Need a 12Epic EMR ImplementationComment by Author 2 Need a
12Epic EMR ImplementationComment by Author 2 Need a
 
12Epic EMR ImplementationComment by Author 2 Need a
12Epic EMR ImplementationComment by Author 2 Need a 12Epic EMR ImplementationComment by Author 2 Need a
12Epic EMR ImplementationComment by Author 2 Need a
 
Electronic Health Records: Implications for IMO State's Healthcare System
Electronic Health Records: Implications for IMO State's Healthcare SystemElectronic Health Records: Implications for IMO State's Healthcare System
Electronic Health Records: Implications for IMO State's Healthcare System
 
Key Ways to Improve EHR Usability and Documentation
Key Ways to Improve EHR Usability and DocumentationKey Ways to Improve EHR Usability and Documentation
Key Ways to Improve EHR Usability and Documentation
 
Powerpoint example
Powerpoint examplePowerpoint example
Powerpoint example
 
Electronic Health Record (EHR) Systems: A Revolution in Healthcare.docx
Electronic Health Record (EHR) Systems: A Revolution in Healthcare.docxElectronic Health Record (EHR) Systems: A Revolution in Healthcare.docx
Electronic Health Record (EHR) Systems: A Revolution in Healthcare.docx
 
These standards are taken from the HL7 Functional Standards for an.docx
These standards are taken from the HL7 Functional Standards for an.docxThese standards are taken from the HL7 Functional Standards for an.docx
These standards are taken from the HL7 Functional Standards for an.docx
 
How to Complete Patient Documentation on Time
How to Complete Patient Documentation on TimeHow to Complete Patient Documentation on Time
How to Complete Patient Documentation on Time
 
Patient Care Clinical Workflow
Patient Care Clinical Workflow Patient Care Clinical Workflow
Patient Care Clinical Workflow
 
eHealth for Africa
eHealth for AfricaeHealth for Africa
eHealth for Africa
 
4.1 Shared care & Electronic Health Record
4.1 Shared care & Electronic Health Record4.1 Shared care & Electronic Health Record
4.1 Shared care & Electronic Health Record
 
Health Information Technology Workforce Development Program Presentation
Health Information Technology Workforce Development Program PresentationHealth Information Technology Workforce Development Program Presentation
Health Information Technology Workforce Development Program Presentation
 
AmericanEHR Partners HIMSS12 Conference HL7 Presentation
AmericanEHR Partners HIMSS12 Conference HL7 PresentationAmericanEHR Partners HIMSS12 Conference HL7 Presentation
AmericanEHR Partners HIMSS12 Conference HL7 Presentation
 
Meaningful Use
Meaningful UseMeaningful Use
Meaningful Use
 
ecoa Application
ecoa Applicationecoa Application
ecoa Application
 
ecoa Application
ecoa Applicationecoa Application
ecoa Application
 
Transforming Nursing And Healthcare Through Technology.docx
Transforming Nursing And Healthcare Through Technology.docxTransforming Nursing And Healthcare Through Technology.docx
Transforming Nursing And Healthcare Through Technology.docx
 
Introduction to Data Entry and Electronic Health Record.pdf
Introduction to Data Entry and Electronic Health Record.pdfIntroduction to Data Entry and Electronic Health Record.pdf
Introduction to Data Entry and Electronic Health Record.pdf
 
Meaningful Use
Meaningful UseMeaningful Use
Meaningful Use
 
1.01 health science career cluster pathways
1.01 health science career cluster pathways1.01 health science career cluster pathways
1.01 health science career cluster pathways
 

More from AudioEducator

Physician Compensation Report 2016
Physician Compensation Report 2016Physician Compensation Report 2016
Physician Compensation Report 2016
AudioEducator
 
MACRA – 3 Important Medicare Payment Changes Infographic
MACRA – 3 Important Medicare Payment Changes InfographicMACRA – 3 Important Medicare Payment Changes Infographic
MACRA – 3 Important Medicare Payment Changes Infographic
AudioEducator
 
10 Healthcare Predictions for 2016
10 Healthcare Predictions for 201610 Healthcare Predictions for 2016
10 Healthcare Predictions for 2016
AudioEducator
 
What's In a Label: GMO, Natural, and Organic Labeling Issues
What's In a Label: GMO, Natural, and Organic Labeling IssuesWhat's In a Label: GMO, Natural, and Organic Labeling Issues
What's In a Label: GMO, Natural, and Organic Labeling Issues
AudioEducator
 
Writing Effective SOP’s
Writing Effective SOP’sWriting Effective SOP’s
Writing Effective SOP’s
AudioEducator
 
The Compliance Coach
The Compliance CoachThe Compliance Coach
The Compliance Coach
AudioEducator
 
Urological Non Surgical Hospital Coding for 2014
Urological Non Surgical Hospital Coding for 2014 Urological Non Surgical Hospital Coding for 2014
Urological Non Surgical Hospital Coding for 2014
AudioEducator
 
Modifier Use in Urology, 2014
Modifier Use in Urology, 2014Modifier Use in Urology, 2014
Modifier Use in Urology, 2014
AudioEducator
 
US, EU & Japan GMP Requirements: Practical ICH Area Differences & Healthcare ...
US, EU & Japan GMP Requirements: Practical ICH Area Differences & Healthcare ...US, EU & Japan GMP Requirements: Practical ICH Area Differences & Healthcare ...
US, EU & Japan GMP Requirements: Practical ICH Area Differences & Healthcare ...
AudioEducator
 
OASIS C1 - Are you ready?
OASIS C1 - Are you ready?OASIS C1 - Are you ready?
OASIS C1 - Are you ready?
AudioEducator
 
US Regulations for Food, Drugs, Medical Devices and Cosmetics
US Regulations for Food, Drugs, Medical Devices and CosmeticsUS Regulations for Food, Drugs, Medical Devices and Cosmetics
US Regulations for Food, Drugs, Medical Devices and Cosmetics
AudioEducator
 
Sanitary Food Packaging Concepts
Sanitary Food Packaging ConceptsSanitary Food Packaging Concepts
Sanitary Food Packaging Concepts
AudioEducator
 
Revenue Cycle: Tracking Reimbursement for DRGs, APCs and MPFS
Revenue Cycle: Tracking Reimbursement for DRGs, APCs and MPFSRevenue Cycle: Tracking Reimbursement for DRGs, APCs and MPFS
Revenue Cycle: Tracking Reimbursement for DRGs, APCs and MPFS
AudioEducator
 
Regulatory Compliance in the Pharmaceutical Supply Chain
Regulatory Compliance in the Pharmaceutical Supply ChainRegulatory Compliance in the Pharmaceutical Supply Chain
Regulatory Compliance in the Pharmaceutical Supply Chain
AudioEducator
 
Recipe for Success: How to Effectively Manage an Allergen Program
Recipe for Success: How to Effectively Manage an Allergen ProgramRecipe for Success: How to Effectively Manage an Allergen Program
Recipe for Success: How to Effectively Manage an Allergen Program
AudioEducator
 
Radiology for Coders
Radiology for CodersRadiology for Coders
Radiology for Coders
AudioEducator
 
Pediatric coding and documentation challenges
Pediatric coding and documentation challengesPediatric coding and documentation challenges
Pediatric coding and documentation challenges
AudioEducator
 
Pediatric Coding, Billing, and Compliance Update 2015
Pediatric Coding, Billing, and Compliance Update 2015Pediatric Coding, Billing, and Compliance Update 2015
Pediatric Coding, Billing, and Compliance Update 2015
AudioEducator
 
Medical Necessity and Recent Government Scrutiny and Theories of Enforcement
Medical Necessity and Recent Government Scrutiny and Theories of EnforcementMedical Necessity and Recent Government Scrutiny and Theories of Enforcement
Medical Necessity and Recent Government Scrutiny and Theories of Enforcement
AudioEducator
 
Non-Physician Practitioners in General Surgery - What Can They Do and How Can...
Non-Physician Practitioners in General Surgery - What Can They Do and How Can...Non-Physician Practitioners in General Surgery - What Can They Do and How Can...
Non-Physician Practitioners in General Surgery - What Can They Do and How Can...
AudioEducator
 

More from AudioEducator (20)

Physician Compensation Report 2016
Physician Compensation Report 2016Physician Compensation Report 2016
Physician Compensation Report 2016
 
MACRA – 3 Important Medicare Payment Changes Infographic
MACRA – 3 Important Medicare Payment Changes InfographicMACRA – 3 Important Medicare Payment Changes Infographic
MACRA – 3 Important Medicare Payment Changes Infographic
 
10 Healthcare Predictions for 2016
10 Healthcare Predictions for 201610 Healthcare Predictions for 2016
10 Healthcare Predictions for 2016
 
What's In a Label: GMO, Natural, and Organic Labeling Issues
What's In a Label: GMO, Natural, and Organic Labeling IssuesWhat's In a Label: GMO, Natural, and Organic Labeling Issues
What's In a Label: GMO, Natural, and Organic Labeling Issues
 
Writing Effective SOP’s
Writing Effective SOP’sWriting Effective SOP’s
Writing Effective SOP’s
 
The Compliance Coach
The Compliance CoachThe Compliance Coach
The Compliance Coach
 
Urological Non Surgical Hospital Coding for 2014
Urological Non Surgical Hospital Coding for 2014 Urological Non Surgical Hospital Coding for 2014
Urological Non Surgical Hospital Coding for 2014
 
Modifier Use in Urology, 2014
Modifier Use in Urology, 2014Modifier Use in Urology, 2014
Modifier Use in Urology, 2014
 
US, EU & Japan GMP Requirements: Practical ICH Area Differences & Healthcare ...
US, EU & Japan GMP Requirements: Practical ICH Area Differences & Healthcare ...US, EU & Japan GMP Requirements: Practical ICH Area Differences & Healthcare ...
US, EU & Japan GMP Requirements: Practical ICH Area Differences & Healthcare ...
 
OASIS C1 - Are you ready?
OASIS C1 - Are you ready?OASIS C1 - Are you ready?
OASIS C1 - Are you ready?
 
US Regulations for Food, Drugs, Medical Devices and Cosmetics
US Regulations for Food, Drugs, Medical Devices and CosmeticsUS Regulations for Food, Drugs, Medical Devices and Cosmetics
US Regulations for Food, Drugs, Medical Devices and Cosmetics
 
Sanitary Food Packaging Concepts
Sanitary Food Packaging ConceptsSanitary Food Packaging Concepts
Sanitary Food Packaging Concepts
 
Revenue Cycle: Tracking Reimbursement for DRGs, APCs and MPFS
Revenue Cycle: Tracking Reimbursement for DRGs, APCs and MPFSRevenue Cycle: Tracking Reimbursement for DRGs, APCs and MPFS
Revenue Cycle: Tracking Reimbursement for DRGs, APCs and MPFS
 
Regulatory Compliance in the Pharmaceutical Supply Chain
Regulatory Compliance in the Pharmaceutical Supply ChainRegulatory Compliance in the Pharmaceutical Supply Chain
Regulatory Compliance in the Pharmaceutical Supply Chain
 
Recipe for Success: How to Effectively Manage an Allergen Program
Recipe for Success: How to Effectively Manage an Allergen ProgramRecipe for Success: How to Effectively Manage an Allergen Program
Recipe for Success: How to Effectively Manage an Allergen Program
 
Radiology for Coders
Radiology for CodersRadiology for Coders
Radiology for Coders
 
Pediatric coding and documentation challenges
Pediatric coding and documentation challengesPediatric coding and documentation challenges
Pediatric coding and documentation challenges
 
Pediatric Coding, Billing, and Compliance Update 2015
Pediatric Coding, Billing, and Compliance Update 2015Pediatric Coding, Billing, and Compliance Update 2015
Pediatric Coding, Billing, and Compliance Update 2015
 
Medical Necessity and Recent Government Scrutiny and Theories of Enforcement
Medical Necessity and Recent Government Scrutiny and Theories of EnforcementMedical Necessity and Recent Government Scrutiny and Theories of Enforcement
Medical Necessity and Recent Government Scrutiny and Theories of Enforcement
 
Non-Physician Practitioners in General Surgery - What Can They Do and How Can...
Non-Physician Practitioners in General Surgery - What Can They Do and How Can...Non-Physician Practitioners in General Surgery - What Can They Do and How Can...
Non-Physician Practitioners in General Surgery - What Can They Do and How Can...
 

Recently uploaded

Procaine powder cas 51-05-8 safe Transport safety to Europe Netherlands Facto...
Procaine powder cas 51-05-8 safe Transport safety to Europe Netherlands Facto...Procaine powder cas 51-05-8 safe Transport safety to Europe Netherlands Facto...
Procaine powder cas 51-05-8 safe Transport safety to Europe Netherlands Facto...
grandmotherprocess99
 
satyananda suryanamaskar - sun salutation
satyananda suryanamaskar - sun salutationsatyananda suryanamaskar - sun salutation
satyananda suryanamaskar - sun salutation
Karuna Yoga Vidya Peetham
 
Premium Girls Call Mumbai 9910780858 Provide Best And Top Girl Service And No...
Premium Girls Call Mumbai 9910780858 Provide Best And Top Girl Service And No...Premium Girls Call Mumbai 9910780858 Provide Best And Top Girl Service And No...
Premium Girls Call Mumbai 9910780858 Provide Best And Top Girl Service And No...
saroni night girls
 
Mind Sound Resonance Technique (MSRT) Certificate Course.ppt
Mind Sound Resonance Technique (MSRT) Certificate Course.pptMind Sound Resonance Technique (MSRT) Certificate Course.ppt
Mind Sound Resonance Technique (MSRT) Certificate Course.ppt
Karuna Yoga Vidya Peetham
 
Massage Centre Ajman - Malayali Kerala Spa Ajman
Massage Centre Ajman - Malayali Kerala Spa AjmanMassage Centre Ajman - Malayali Kerala Spa Ajman
Massage Centre Ajman - Malayali Kerala Spa Ajman
Malayali Kerala Spa Ajman
 
arm balance asana - Comprehensive understanding of arm balancing asana
arm balance asana - Comprehensive understanding of arm balancing asanaarm balance asana - Comprehensive understanding of arm balancing asana
arm balance asana - Comprehensive understanding of arm balancing asana
Karuna Yoga Vidya Peetham
 
NURS FPX 6109 Assessment 4 Vila Health_ Implementing New Educational Technolo...
NURS FPX 6109 Assessment 4 Vila Health_ Implementing New Educational Technolo...NURS FPX 6109 Assessment 4 Vila Health_ Implementing New Educational Technolo...
NURS FPX 6109 Assessment 4 Vila Health_ Implementing New Educational Technolo...
Carolyn Harker
 
kneeling asana - Comprehensive understanding of kneeling asana
kneeling asana - Comprehensive understanding of kneeling asanakneeling asana - Comprehensive understanding of kneeling asana
kneeling asana - Comprehensive understanding of kneeling asana
Karuna Yoga Vidya Peetham
 
TEMPOROMANDIBULAR JOINT & IT'S BIOMECHANICS.pptx
TEMPOROMANDIBULAR JOINT & IT'S BIOMECHANICS.pptxTEMPOROMANDIBULAR JOINT & IT'S BIOMECHANICS.pptx
TEMPOROMANDIBULAR JOINT & IT'S BIOMECHANICS.pptx
SatvikaPrasad
 
Asthma CPD.pptx.Based on new GINA guidelines
Asthma CPD.pptx.Based on new GINA guidelinesAsthma CPD.pptx.Based on new GINA guidelines
Asthma CPD.pptx.Based on new GINA guidelines
RanaTareq1
 
Burn and Scar management in occupational therapy
Burn and Scar management in occupational therapyBurn and Scar management in occupational therapy
Burn and Scar management in occupational therapy
2023294402
 
Trump vance 2024 t shirts Trump vance 2024 t shirts
Trump vance 2024 t shirts Trump vance 2024 t shirtsTrump vance 2024 t shirts Trump vance 2024 t shirts
Trump vance 2024 t shirts Trump vance 2024 t shirts
exgf28
 
World Health Organization Guidelines on Nutrition .pptx
World Health Organization Guidelines on Nutrition .pptxWorld Health Organization Guidelines on Nutrition .pptx
World Health Organization Guidelines on Nutrition .pptx
MopideviSravani
 
Respectful Care _Special Patient Care for health science students
Respectful Care _Special Patient Care for health science studentsRespectful Care _Special Patient Care for health science students
Respectful Care _Special Patient Care for health science students
Debre Berhan University
 
Adho-Mukha Mudra(Downward Facing Gesture)ppt.ppt
Adho-Mukha Mudra(Downward Facing Gesture)ppt.pptAdho-Mukha Mudra(Downward Facing Gesture)ppt.ppt
Adho-Mukha Mudra(Downward Facing Gesture)ppt.ppt
Karuna Yoga Vidya Peetham
 
Compartment syndrome, meaning , types, causes , nursing management , murugesh...
Compartment syndrome, meaning , types, causes , nursing management , murugesh...Compartment syndrome, meaning , types, causes , nursing management , murugesh...
Compartment syndrome, meaning , types, causes , nursing management , murugesh...
MurugeshHJ1
 
ALTERNATIVE THERAPIES DURING LABOUR.pptx
ALTERNATIVE THERAPIES DURING LABOUR.pptxALTERNATIVE THERAPIES DURING LABOUR.pptx
ALTERNATIVE THERAPIES DURING LABOUR.pptx
BhagyashreeDash6
 
Top 10 Antibiotic Manufacturers in India
Top 10 Antibiotic Manufacturers in IndiaTop 10 Antibiotic Manufacturers in India
Top 10 Antibiotic Manufacturers in India
DM Pharma
 
Female Girls Call Navi Mumbai 🎈🔥9920725232 🔥💋🎈 Provide Best And Top Girl Serv...
Female Girls Call Navi Mumbai 🎈🔥9920725232 🔥💋🎈 Provide Best And Top Girl Serv...Female Girls Call Navi Mumbai 🎈🔥9920725232 🔥💋🎈 Provide Best And Top Girl Serv...
Female Girls Call Navi Mumbai 🎈🔥9920725232 🔥💋🎈 Provide Best And Top Girl Serv...
bellared2
 
Ion-S5-S5XL-App-Note-Infectious-Disease.pdf
Ion-S5-S5XL-App-Note-Infectious-Disease.pdfIon-S5-S5XL-App-Note-Infectious-Disease.pdf
Ion-S5-S5XL-App-Note-Infectious-Disease.pdf
ALIY12
 

Recently uploaded (20)

Procaine powder cas 51-05-8 safe Transport safety to Europe Netherlands Facto...
Procaine powder cas 51-05-8 safe Transport safety to Europe Netherlands Facto...Procaine powder cas 51-05-8 safe Transport safety to Europe Netherlands Facto...
Procaine powder cas 51-05-8 safe Transport safety to Europe Netherlands Facto...
 
satyananda suryanamaskar - sun salutation
satyananda suryanamaskar - sun salutationsatyananda suryanamaskar - sun salutation
satyananda suryanamaskar - sun salutation
 
Premium Girls Call Mumbai 9910780858 Provide Best And Top Girl Service And No...
Premium Girls Call Mumbai 9910780858 Provide Best And Top Girl Service And No...Premium Girls Call Mumbai 9910780858 Provide Best And Top Girl Service And No...
Premium Girls Call Mumbai 9910780858 Provide Best And Top Girl Service And No...
 
Mind Sound Resonance Technique (MSRT) Certificate Course.ppt
Mind Sound Resonance Technique (MSRT) Certificate Course.pptMind Sound Resonance Technique (MSRT) Certificate Course.ppt
Mind Sound Resonance Technique (MSRT) Certificate Course.ppt
 
Massage Centre Ajman - Malayali Kerala Spa Ajman
Massage Centre Ajman - Malayali Kerala Spa AjmanMassage Centre Ajman - Malayali Kerala Spa Ajman
Massage Centre Ajman - Malayali Kerala Spa Ajman
 
arm balance asana - Comprehensive understanding of arm balancing asana
arm balance asana - Comprehensive understanding of arm balancing asanaarm balance asana - Comprehensive understanding of arm balancing asana
arm balance asana - Comprehensive understanding of arm balancing asana
 
NURS FPX 6109 Assessment 4 Vila Health_ Implementing New Educational Technolo...
NURS FPX 6109 Assessment 4 Vila Health_ Implementing New Educational Technolo...NURS FPX 6109 Assessment 4 Vila Health_ Implementing New Educational Technolo...
NURS FPX 6109 Assessment 4 Vila Health_ Implementing New Educational Technolo...
 
kneeling asana - Comprehensive understanding of kneeling asana
kneeling asana - Comprehensive understanding of kneeling asanakneeling asana - Comprehensive understanding of kneeling asana
kneeling asana - Comprehensive understanding of kneeling asana
 
TEMPOROMANDIBULAR JOINT & IT'S BIOMECHANICS.pptx
TEMPOROMANDIBULAR JOINT & IT'S BIOMECHANICS.pptxTEMPOROMANDIBULAR JOINT & IT'S BIOMECHANICS.pptx
TEMPOROMANDIBULAR JOINT & IT'S BIOMECHANICS.pptx
 
Asthma CPD.pptx.Based on new GINA guidelines
Asthma CPD.pptx.Based on new GINA guidelinesAsthma CPD.pptx.Based on new GINA guidelines
Asthma CPD.pptx.Based on new GINA guidelines
 
Burn and Scar management in occupational therapy
Burn and Scar management in occupational therapyBurn and Scar management in occupational therapy
Burn and Scar management in occupational therapy
 
Trump vance 2024 t shirts Trump vance 2024 t shirts
Trump vance 2024 t shirts Trump vance 2024 t shirtsTrump vance 2024 t shirts Trump vance 2024 t shirts
Trump vance 2024 t shirts Trump vance 2024 t shirts
 
World Health Organization Guidelines on Nutrition .pptx
World Health Organization Guidelines on Nutrition .pptxWorld Health Organization Guidelines on Nutrition .pptx
World Health Organization Guidelines on Nutrition .pptx
 
Respectful Care _Special Patient Care for health science students
Respectful Care _Special Patient Care for health science studentsRespectful Care _Special Patient Care for health science students
Respectful Care _Special Patient Care for health science students
 
Adho-Mukha Mudra(Downward Facing Gesture)ppt.ppt
Adho-Mukha Mudra(Downward Facing Gesture)ppt.pptAdho-Mukha Mudra(Downward Facing Gesture)ppt.ppt
Adho-Mukha Mudra(Downward Facing Gesture)ppt.ppt
 
Compartment syndrome, meaning , types, causes , nursing management , murugesh...
Compartment syndrome, meaning , types, causes , nursing management , murugesh...Compartment syndrome, meaning , types, causes , nursing management , murugesh...
Compartment syndrome, meaning , types, causes , nursing management , murugesh...
 
ALTERNATIVE THERAPIES DURING LABOUR.pptx
ALTERNATIVE THERAPIES DURING LABOUR.pptxALTERNATIVE THERAPIES DURING LABOUR.pptx
ALTERNATIVE THERAPIES DURING LABOUR.pptx
 
Top 10 Antibiotic Manufacturers in India
Top 10 Antibiotic Manufacturers in IndiaTop 10 Antibiotic Manufacturers in India
Top 10 Antibiotic Manufacturers in India
 
Female Girls Call Navi Mumbai 🎈🔥9920725232 🔥💋🎈 Provide Best And Top Girl Serv...
Female Girls Call Navi Mumbai 🎈🔥9920725232 🔥💋🎈 Provide Best And Top Girl Serv...Female Girls Call Navi Mumbai 🎈🔥9920725232 🔥💋🎈 Provide Best And Top Girl Serv...
Female Girls Call Navi Mumbai 🎈🔥9920725232 🔥💋🎈 Provide Best And Top Girl Serv...
 
Ion-S5-S5XL-App-Note-Infectious-Disease.pdf
Ion-S5-S5XL-App-Note-Infectious-Disease.pdfIon-S5-S5XL-App-Note-Infectious-Disease.pdf
Ion-S5-S5XL-App-Note-Infectious-Disease.pdf
 

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 Follow us :
  • 2. Objectives © 2011 Rising Tide 2 1. Review documentation requirements for the Electronic Health Record (EHR) 2. Explain guidelines for the appropriate use of “copy forward” in the EHR to ensure medical record integrity 3. Distinguish “copy forward” versus “refer to” functions of the EHR 4. Risks of using “copy forward” and practices to avoid
  • 3. Introduction • Clinicians use the EHR to make decisions about patient care • The quality and integrity of EHR content is important • The EHR is a legal document, it should be compliant with applicable legal requirements or standards • The EHR also is a business record © 2011 Rising Tide 3
  • 4. Our Patient Empowered Care (PEC) Model © 2011 Rising Tide 4
  • 5. Objective 1: Review documentation requirements for the Electronic Health Record (EHR) 1. Notes should be concise, accurate, non-redundant, and easy to read. 2. Progress notes accurately describe treatment for a specific date of service. 3. Place emphasis on the “assessment and plan” portion of the note with the most definitive diagnosis to communicate the clinical reasoning behind the plan. 4. Each note should stand alone, support medical necessity, and support the level billed. 5. It is risky to duplicate information that does not specifically impact a date of service. © 2011 Rising Tide 5
  • 6. To see the complete presentation check the below link: http://www.audioeducator.com/medical-coding-billing/copy-forward- functionality-dos-donts-11-20-2014.html

Editor's Notes

  1. The objectives of this session are as follows: (read 1 – 4 off of slide)
  2. 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. 
  3. 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.
  4. 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.