|Title: Electronic Medical Records (EMR) Key Documentation Standards|
The purpose of this standard is to set standards for documentation within the electronic medical record (EMR) based on the following key assumptions:
Key Assumption #1: Clinical Professionalism extends to the documentation of your services. When Healthcare Professionals sign their clinical notes, they are taking full responsibility for its content.
Key Assumption #2: The medical record serves first to document the care provided to our patients. In addition, it is a legal document and the official record that is used to:
- establish the medical necessity for the services provided
- support quality reporting measures
- support claims for reimbursement from third party payers.
Key Assumption #3: Entries in the electronic medical record should be appropriately concise, timely, relevant and pertinent to the patient’s condition on the date the entry is made.
- Authenticity and Confidentiality
- Passwords must not be shared
- You may not chart in a medical record that has been opened under someone else’s password
- When leaving electronic PHI unattended, you must utilize the suspend or log out function.
- Authorship Integrity
- Each entry in the patient record will be time and date stamped by the author (the password that opened the chart.)
- It is not permissible to copy patient‐specific documentation from another author, unless attribution is included.
- Documentation Integrity
- Documentation must be specific to a patient’s condition at the time of his/her encounter and must accurately represent the services rendered to the specific patient and the specific date of service.
- Templates must be based on clinically appropriate standards of practice.
- Patient‐specific auto‐text and macros may not be shared between providers.
- Macros, auto texts and pre‐completed notes must be edited, updated or confirmed to reflect current findings.
- Pre completed notes should never contain patient specific information.
- Documentation must reflect a positive or active choice when making entries into the medical record. For example:
- Positive choices include checking a box, selecting templated documentation elements, typing free text or selecting from a drop down menu.
- Patient specific unique entries for all procedures must be documented within the templates.
- Appropriate use of Copy Functionality
- Entries carried forward from a patient’s previous visit(s) must be medically necessary, relevant to the patient and services provided for each date‐of‐service. Each entry must be reviewed for accuracy and edited appropriately.
- Entries may not be copied from patient to patient.
- Medical student notes must be documented in the medical student note type. Referencing medical student notes must be limited to the Review of Systems and Past Family Social History and must be attributed to the medical student.
- The History of Present Illness (HPI) may only be copied forward if it is updated with interim history.
- All other elements of the note may only be copied forward if they are updated, edited or confirmed to reflect current findings.
- Coder Integrity
- Providers and Coders are responsible for selecting CPT and ICD‐CM codes that most accurately represent the medically necessary services they have performed and documented.
- Decision support logic that suggests possible CPT codes should only be viewed as guidance. It remains the responsibility of the provider to select the accurate CPT code.
- Sanctions for violations of these standards for faculty will be in accordance with the Faculty Handbook, the general provisions incorporated into faculty appointment letters as applicable, and USC Care and hospital medical staff rules and regulations.
- Sanctions for violations of these standards for staff will be in accordance with the Staff Employment Policies and Procedures
- Any disciplinary action against faculty or staff should take into account the scale of the offense, the individual’s intent and the degree of wrongdoing.
Questions regarding policies, procedures or interpretations should be directed to the USC Office of Culture, Ethics and Compliance at (323) 442-8588 or USC Report & Response at (213) 740-2500 or (800) 348-7454.