Clinical Documentation: How to Avoid Documentation Pitfalls in the EMR

This clinical documentation webinar will discuss how to appropriately document in the history, physical exams, and assessment and plan section of the EMR. It will also provide practical tips on designing templates, as well as avoiding common audit pitfalls.

Why Should You Attend:

Proper clinical documentation in the electronic medical record is crucial to ensure maximum reimbursement but also ensure compliance.

Knowing how to properly document in the Electronic Medical Record will ensure the providers are documenting to the highest level of specificity for maximum reimbursement. It also decreases the chances of a negative finding during an audit. Proper documentation also allows for the transfer of information between parties to be much easier with less errors.

This training will provide practical tips on how to populate the history, physical exams and assessment and plan section of the EMR. It will also give tips on designing templates that meet compliance standards, as well as avoid common audit pitfalls.

Areas Covered in the Webinar:

• How to appropriately document in the history, physical exam, and assessment/plan so it is compliant while meeting all CMS documentation guidelines
• How to design a template that works for the group but also ensures the note meets all compliance standards
• Pitfalls many face in audits - copy and paste, bringing forth old information, point and click
• Communicating to doctors the importance of proper documentation rather than just pointing and clicking -Who can document what in the EMR

Who Will Benefit:

• Practice Managers
• Office Managers
• Compliance Officers
• Medical Billers
• Medical Coders
• MD, DO, NP, PA
• Clinical Documentation Improvement Specialists
• MR Auditors
• Front Desk