Season 9 - Episode 402 - #TerryTuesday - Is Your EMR Crap?

Summary

In this episode, Sean Weiss and Terry Fletcher discuss the critical importance of complete and accurate medical documentation in healthcare. They explore the consequences of incomplete records, the role of electronic medical records (EMRs), and the need for accountability among healthcare providers. The conversation emphasizes that clinicians must take responsibility for their documentation to ensure compliance and support medical necessity. The episode also touches on the complexities of medical coding and the importance of clear communication in clinical records.

Takeaways

• Incomplete documentation can lead to compliance issues.
• Providers must accept accountability for their documentation.
• EMRs should not be blamed for incomplete records.
• Documentation must support medical necessity and clinical judgment.
• Auditors need complete records to defend against claims.
• Assumptions in documentation can lead to errors.
• Clear definitions in coding are essential for accurate billing.
• Providers should not rely on templates to convey critical information.
• Documentation standards change regularly and must be adhered to.
• Healthcare professionals must work together to ensure complete records.