EMR / Clinical Documentation

Clinical Documentation

Documenting the clinical encounter is at the heart of every patient visit and the Clinical eNotes EMR makes accomplishing this task easier and more efficient.

The system  follows the typical format all physicians use when seeing patients beginning with the HPI followed by the ROS, PMH, Medication review and physical exam.

It also adds the necessary data collection unique to hospice and palliative care by easily documenting the patients functional status, patients wishes and end of life discussions.

• The HPI allows for structured data entry to more easily measure outcomes. For example, when asking the patient about pain, it prompts for collection of certain data elements (duration, timing, quality, severity etc) and then presents the selections in a narrative format. This allows for proper presentation of the data in a printed note to be put in a paper chart while providing the ability to query the data for future analysis.
• The assessment and plan section is very intuitive and begins by listing each symptom mentioned in the chief complaint or reason for consult. It then automatically links every treatment ordered to the proper symptom or diagnosis. There is a new requirement that all prescriptions list the reason a medication is being ordered and this linking the prescription to the symptom or diagnosis allows for it to be automatically added to the written prescription.

Clinical eNotes' flexibility allows you to set up visit profiles which might include differing information.For example, you could set up an initial consult profile that would be comprehensive and include all data elements for a complete history and physical while you also set up a follow up visit profile that has a more limited focus in data collection.

Documentation is definitely made easier by allowing the importation of information collected at an earlier visit even if done by a different provider. And you can choose which visit date to import data for each section such as the ROS, PMH or PE. Of course this only assists in documentation, it is the clinician's responsibility to review all the imported information and make appropriate changes which will then update the patients record. For example, if you import data that says the patient is a full code but then edit that to a DNR status based on a new discussion you had with the patient, the patients chart will be updated reflecting this change in code status.

Billing

Selecting the proper CPT code for procedures and services rendered during a visit can be daunting and errors in both under and over coding exist. Under coding can lead to lower reimbursement and not being paid appropriately while over coding can lead to penalties when audited.

The proper CPT code is based on several factors along with the amount of clinical information documented in the note. The system will present only those potential CPT codes that meet the chosen factors of visit type, visit location and role of clinician so a CPT code for a nursing home visit could not be inadvertently listed when the visit was done in the home. It will also go one step further and suggest the code for which there is sufficient clinical documentation to support that level of billing. Each clinician must choose the CPT code he/she wishes but this allows analysis of coding trends for both over and under coding.

Electronic Signature

After completing the clinical documentation, you electronically sign the note which is then closed and becomes unavailable for editing. Future changes can then only be made via a comment which is added to the end of the note and is included with each subsequent print session.

The electronic signature meets all the criteria of authorization, authentication and non-repudiation.