Since the implementation of EHR, the patient flow chart, formerly paper, has been transferred to an electronic record known as the patient health record or the electronic health record.
The rule “if it isn’t documented, it wasn’t done” still applies, however depending on the type of software used in the medical setting you are working in, will play a significant role in how in depth the Key Components are documented.
The EHR was designed to meet government mandates, monitor HIPAA code sets and regulate reimbursement. A problem that has come about is that the shortcuts, or templates also known as macros or fields, limit the details of a clinical record.
Because of such problems within the first year of implementation, the CMS published what
The rule “if it isn’t documented, it wasn’t done” still applies, however depending on the type of software used in the medical setting you are working in, will play a significant role in how in depth the Key Components are documented.
The EHR was designed to meet government mandates, monitor HIPAA code sets and regulate reimbursement. A problem that has come about is that the shortcuts, or templates also known as macros or fields, limit the details of a clinical record.
Because of such problems within the first year of implementation, the CMS published what