Documentation and the Electronic Medical Record
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Expert Tips to Ensure Accurate & Compliant Documentation in EMRs to Avoid Audits!
Knowing how to properly document in the Electronic Medical Record ensure the providers are documenting to the highest level of specificity so the group is paid at the correct level. Plus, it also decreases the chances of a negative finding during an audit. Moreover, proper documentation also allows for the transfer of information between parties to be much easier with fewer errors. Our expert speaker Dreama Sloan-Kelly will share guidelines on how to populate the history, physical exams and assessment and plan section of the EMR. Besides, you get some insights on designing templates, as well as common audit pitfalls.
Here are a few topics covered in the session:
- Ensure that your EMR Documentation practices are compliant & meet all CMS guidelines.
- Paper Records versus EMR - Analysis and Takeaways
- Key Issues & Areas of concern with Paper Records
- Transition Plan & What you don’t know about your EMR
- How to design a template that works for the group but also ensures the note meets all compliance standards?
- Pitfalls may face in audits – copy and paste, bringing forth old information, point and click
- Over Documentation & How to document in your EMR
- How to manage the History of the patient
- Physical Exams documentation & Organ systems recognized
- Types of Pateints and how it effects your documentation and billing practices.
- Guidelines for Medical Decision Making (MDM)
- Compliance Challenges to keep up with.
- Communicating to doctors the importance of proper documentation rather than just pointing and clicking
- Who can document what in the EMR?
- And much more…
Who should attend? All Specialties -- Practice Managers, Office Managers, Compliance Officers, C-Level Staff, Medical Billers, Medical Coders, MD, DO, NP, PA, Clinical Documentation Improvement Specialists, MR Auditors, Front Desk
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About Our Speaker
Dreama Sloan-Kelly, MD, CCS, a graduate of Wellesley College and Tufts University School of Medicine, has a varied background including clinical, and medical billing/coding.
Dreama speaks at various seminars, imparting her knowledge to a larger healthcare audience. She shares pertinent information to the attendee, minimize the nonsense, and makes sure everyone has fun at the same time.
Dreama works with practices one on one, through coding... More Info
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