Being proactive can make a big difference in the audit process.

As an auditor, I see chart documentation in paper charts and in a multitude of EHR systems. However, none of the documentation looks the same. Even though the basic content is similar and the flow might be comparable, one chart document can look very different from another.

Different providers may want the template to look a certain way based on their training and how they learned to document. The EHR documentation format and flow may be customized to adapt to the provider’s style of documentation. Still, whether on paper or in an EHR, all charts have certain requirements.

With ongoing Targeted Probe and Educate (TPE) audits by the CMS, it is important to ensure your medical record documentation is up to the review.

Medical record entries must be ‘complete.’

A complete medical record has the appropriate information to identify the patient, support the diagnosis or condition being treated, the treatment for the diagnosis or condition, and the course and outcome of the treatment. Additionally, entries in the medical record must be dated and authenticated.

In an EHR, authentication occurs with the unique username and password that each employee and provider use to access the EHR. In a paper record, authentication of the provider signature or initials can be accomplished with a legible signature or, when the signature is not legible, an “initial and signature log” for the practice containing the typed name and initials of each provider along with the provider’s handwritten initials and signature.

Although there is no specific requirement by CMS, some commercial payers require that each page of the medical record, including data and images from diagnostic testing, contain identifying information like the patient name or medical record number (or both) and the date of service. If pages are separated after submitting documentation for medical review, the reviewer can match them back to the appropriate file if each page contains this information. In a paper chart, most pages have the patient name on the front of the entry, but rarely does it also appear on the backside. When photocopied, the identifying information to which patient the document belongs will not be included.

Medical record entries must be legible.

Legible does not mean that only the provider who wrote the information should be able to read it. Legibility is important to prevent medical errors or adverse patient events. This requirement is easy for practices using EHR but, for practices using paper charts, this requirement can be a concern.

Medical record entries should be completed in a timely fashion.

Some EHR systems lock the document at midnight, so no additional changes can be made without creating an amendment. If an amendment needs to be made, be sure to follow appropriate documentation rules.

Other systems are not as restrictive. However, to ensure the entry is correct, it is a good habit to complete the chart on the same day the patient is seen.

While there are many formats for paper chart documentation and just as many formats for EHR documentation, it is important to pay attention to the details that can make a difference in the audit process. Often it is the little things that matter. OP