An electronic medical record is created for every patient who receives treatment, care or services, and is maintained for the primary purpose of providing patient care.
The record should contain sufficient information to identify the patient, support the diagnosis, justify treatment and facilitate the continuity of care. Electronic medical records must comply with all HIPAA privacy and security requirements.
Per CMS Transmittal 455, dated March 15, 2013 use of templates is not prohibited to facilitate recordkeeping, but CMS also does not endorse or approve any particular templates. Providers may choose any template to assist in documenting medical information. However, CMS does discourage the use of templates which provide limited options such as “check boxes” or predefined answers, and/or limited space to enter information, or those designed to gather selected information focused primarily for reimbursement purposes as they often fail to capture sufficient detailed clinical information to demonstrate that all coverage and coding requirements are met, or adequately show that medical necessity criteria for the service are meant.
If using a template, UBMD providers are advised to select one that allows for a full and complete collection of information to demonstrate that the applicable coverage and coding criteria, as well as medical necessity, are met.
Documentation is considered cloned when it is worded exactly like, or similar to, previous entries. It can also occur when the documentation is exactly the same from patient to patient. Individualized patient notes for each patient encounter are required. Documentation must reflect the patient condition necessitating treatment, the treatment rendered and, if applicable, the overall progress of the patient to demonstrate medical necessity.
Electronic Health Records should be audited at the practice plan level by each practice plan on a quarterly basis as follows:
Any employee found to be inappropriately accessing the EHR of a patient will face disciplinary action up to and including termination.