chiropractic CEU Online & EHR Progress Notes: Avoid Cloning and Uphold Medical Ethics in Your Chiropractic Practice Posted on Sep 12, 2023
As the transition from handwritten to electronic health record (EHR) systems fostered efficiency in the medical field, it also introduced a dubious practice: cloning EHR progress notes. This involves copying and pasting segments of notes from one patient encounter to another, a practice that is not just ethically incorrect but is considered fraud.
CCEDseminars | Your Premiere Destination For Chiropractic CEU Online!Understanding the Implications of Cloning
Cloning does save time, but at a significant cost. It often leads to inaccurate records, portraying a stagnation in the patient's condition due to repeated information. This repetitive nature of the notes can signal a lack of medical necessity, calling into question the integrity of the practitioner and potentially leading to legal issues.
Moreover, the misrepresentation of a patient’s progression can attract scrutiny and denials from Medicare and other organizations, especially as it fails to demonstrate an “improving as expected” trajectory for the patient. CCEDseminars provides extensive chiropractic CEU online training that will "Bullet Proof Your Practice". Click HERE for more information.
The Rise and Fall of “Note Bloat”
In the past, longer, more detailed notes were advocated to potentially gain higher reimbursement levels. However, this led to "note bloat," resulting in unnecessarily voluminous notes that failed to offer genuine insight into a patient's condition.
The Merits of EHR and the Importance of Accuracy
Despite the challenges posed by EHR systems, they have proven their worth, especially in situations like natural disasters where cloud-based storage systems protected patient data from being destroyed. However, the misuse of features such as auto-fills and auto-prompts can distort patient records, giving rise to legal complications and damaging the reputation of the provider.
Maintaining Integrity in Cash Practices
Even cash practices, which may feel immune to such scrutiny due to the absence of direct insurance claims, are mandated to maintain proper documentation and record-keeping as per guidelines set by the National Board of Chiropractic Examiners for each state. Compliance with these regulations safeguards practices from potential litigations and investigations.
The Path Forward: Self-Audit and Compliance
Chiropractic practices need to undertake self-audits to check for cloning and inaccurate statements in their EHR progress notes. Further, seeking the review of a certified specialist can help identify risky business practices, ensuring records are timely, authenticated, and correctly detailed to create a comprehensive story of the patient’s complaints, examination findings, and responses to care.
Conclusion: Upholding Ethics and Improving Care
EHR systems were introduced to streamline operations and enhance efficiency in medical practices. While the advent of cloning contradicts these objectives, maintaining ethical standards in documentation can steer chiropractic practice towards better patient care, improved outcomes, and a stellar professional image. CCEDseminars provides training for every practice regarding Documentation. Please click HERE for our chiropractic CEU online courses!
Cherishing the duty towards patient care requires the establishment of meticulous documentation habits, focusing on the accuracy of EHR progress notes rather than mere convenience. Let's preserve the sanctity of our profession by adhering to the principles of honesty and precision in our practices.