How To Avoid Cloning Medical Records with EHRs

Coding and BillingNo Comments

In this month’s publication of AAPC Healthcare Business, an article about Electronic Health Records caught my attention. It was titled Set Up Templates So Cloning Is Not Questioned.

The article talked about how often medical records end up looking like clones of each other when transitioning to EHR (electronic health records). This reminds me of living in suburban neighborhoods where every house seems exactly the same. In order to have a unique medical record that makes you distinguishable from your neighbor a unique template can be used to insert personal information instead of copying and pasting components and pieces of medical records together. Each piece of information should pertain to the encounter and to the patient, not be based on how the last visit went with a previous patient. 

We don’t want a clone of another medical record, or yet another brown stucco home—yuck! Another cookie cutter home does not satisfy my need to see some variety in the community the same way that a cloned medical record does not meet medical requirements.

The author, Ronda Tews, stated, “Each patient encounter should be distinct and separately identifiable from other patient encounters.” She recommends creating customized templates to cover a variety of E/M level needs. 

Read the full article on the AAPC website: http://news.aapc.com/index.php/2014/06/set-up-templates-so-cloning-is-not-questioned/.


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