The June 2014 cover story of the American Association of Professional Coders “Monthly Business Journal” included an article written by Dr. Michael Stearns on the use of tools that import text into electronic health records (EHRs). This includes the use of text imported (copy and paste/cloning) brought in from other notes in the EHR or other sources, templates, and macros. These tools have value in patient care and the efficiency of documentation. However, concerns over the misuse of imported text, including its potential to create medical errors and falsely elevate coding levels is an area of focus for the Office of Inspector General, the U.S. Congress, and other regulatory bodies.
EHR users need to be aware of the pitfalls of importing text into clinical records.
A copy of the article is available here: Import Text Properly Michael Stearns AAPC June 2014
For additional information please contact Michael Stearns, MD at firstname.lastname@example.org