E/M clinical documentation errors and EHR compliance failures summary

COMMON E/M CLINICAL DOCUMENTATION ERRORS SUMMARY

F Incomplete patient identification info (Ex. Member ID info on all pages).

F Missing date of service (DOS)

F Chief complaint not documented.

F HPI documented by a non-provider and without the provider review acknowledgement. 

F Incomplete review of systems.

F No status on chronic conditions review.

F Mix of body areas with organ systems.

F Lack of documentation on the exam (Ex. Abnormal results without findings).

F Lack of documentation on the assessment and plan (Ex. Incomplete medical decision making).

F Incomplete documentation of diagnosis, orders and medication.

F Incomplete documentation of interpretations/lab review, procedures and/or ancillary services performed.

F Incorrect documentation of time based and consultation visits.   

F Inconsistent documentation (Ex. Unknown abbreviations).

F Medical necessity not supported.

F Multiple non-identified authors.

F Out of time completion (Ex. DOS vs. closing date).

F No provider signatures, license and/or specialty.

Electronic Health Records documentation compliance failures

F Doesn’t follow E/M 1995 or 1997 rules.

F The provider was not involve in the design or implementation phase.

F Non customizable notes with little or none free text.

F Missing documentation specific to the practice (Ex. Specialty appropriate).

F Inconsistency with clinical workflow.

F Click friendly, not story teller or reader friendly.

F Repetitive documentation (Ex. Copy/paste notes).

F Easy to skip parts.

F Ending and closing the note without review or authentication.

F Non-automated signatures, license, specialty and DOS.

F No alerts for incomplete notes.

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