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Cloning Office Notes with your EHR: Science Fiction or Compliance Risk?

Cloning Office Notes with your EHR: Science Fiction or Compliance Risk?


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Betsy Nicoletti, MS, CPC and Ron Sterling, CPA

Hear two powerhouse speakers, Betsy Nicoletti and Ron Sterling, collaborate for 90-minutes on this very important topic of cloning office notes and your EHR. The 2011 Office of Inspector General Work Plan identifies " "identical" " notes as an area of interest in physician practices. The OIG is looking at notes that are copied and pasted from a previous visit, by the same or different clinician. With physician practices moving to Electronic Health Records (EHRs) at a galloping clip, how can a practice avoid this pitfall and still take advantage of the capabilities of the EHR?

This audio conference will instruct physician practices how to avoid these traps:

  • Burying the lead: why the most important information is the hardest to find in these notes
  • Pre-documenting the record: The patient didn't show for the appointment, but the documentation is 90% done
  • Written by " "Anonymous:" " This is fine for a Victorian novel, but all entries into the medical record must be signed
  • His, hers, ours: What can you copy from a previous encounter
  • History of the present illness or past medical history: Which specialties are prone to call one the other, and copy, copy, copy from month to month and year to year
  • The acid test: Would the clinician have dictated the information? If not, is it medically necessary? If it's not relevant, is it counted to determine the level of service
  • And more --

  • EHR Design issues that affect cloning
  • Technical versus practice strategies to address cloning issues
  • Clinical validation issues that impact use and exposure
  • Malpractice issues with cloning
  • E&M Standards effect on EHRs and thereby cloning
  • Tune in to this audio conference to hear Betsy Nicoletti and Ron Sterling explain how to use-not abuse-your EHR.

    Meet Our Expert Speakers:

    Betsy Nicoletti is the co-founder of Codapedia.com, a website which is dedicated to providing user-generated, free reimbursement information for physician practices. She is also the author of the Physician Auditing Workbook, published by DecisionHealth and The Field Guide to Physician Coding published by Greenbranch Publishing.

    Betsy speaks nationally on coding education.

    In addition to writing and speaking, Betsy educates physicians and coders and helps practices with complying with government regulations while collecting all of the reimbursement they are entitled to collect. He consulting firm is Medical Practice Consulting.

    Ronald B. Sterling authored the HIMSS Book of Year Award winning Keys to EMR/EHR Success. Ron, President of Sterling Solutions, Ltd. is a nationally recognized expert on the selection and implementation of electronic health record (EHR) and practice management systems. He is independent and has worked with a wide array of practices, clinics, and healthcare organizations in 35 states.

    Ron Sterling offers high impact ideas and valuable insights on how to use EHR systems to improve patient service and practice results. He has reviewed electronic healthcare record and practice management systems from over 150 vendors. He is a frequent contributor to a wide range of publications including the widely used Marketing You Clinical Practice.
    Moderator: Nancy Collins, Publisher of The Journal of Medical Practice Management®