Electronic Health Records and Coding: Practical Workflow, Data Quality, and Reimbursement

electronic health record (EHR)

The digital version of a patient’s clinical chart, including notes, orders, results, medications, and allergies.

SOAP

A method for documenting progress notes: Subjective, Objective, Assessment, Plan.

medication administration records (MAR)

Documents that track medications given to a patient, including dosage and timing.

medication reconciliation

The process of confirming a patient's current medications to avoid errors.

copy-forward/copy-paste

A common error where outdated information is carried into a current note.

health information exchanges (HIEs)

Networks that enable the sharing of patient data across different health care systems.

clinical decision support (CDS)

Tools that help healthcare providers make informed clinical decisions based on patient data.

audit trails

Records that show who accessed or changed information in an EHR and when.

scope of practice

The legally defined tasks and decisions a healthcare provider is permitted to perform.

minimum necessary

A principle requiring individuals to access only the information necessary for their tasks.

role-based access control (RBAC)

A system that restricts access to information based on the user's role.

indexing

The process of filing a document under the correct patient, encounter, date, and document type.

version control

Managing different versions of a document to ensure accuracy and integrity.

release of information (ROI)

Providing patient records to authorized entities while ensuring compliance.

Medical coding

The process of translating clinical documentation into standardized codes used for reimbursement.

CMS-1500

A claim form commonly used for professional services billing in the U.S.

UB-04 (CMS-1450)

A claim form commonly used for facility billing in the U.S.

timely filing

The requirement to submit claims within a specified time frame to ensure payment.

authentication

The process of validating the identity of a user to secure access to EHR information.

cross-checking

The practice of verifying information from different sources to ensure its accuracy.

structured fields

Pre-defined input fields within an EHR that guide data entry for consistency.

narrative entry

Free-text documentation in an EHR that provides detailed explanation or context.

alert fatigue

A situation where users become desensitized to alerts, which can lead to ignoring important warnings.

source verification

Confirming the origin of information, particularly when documentation is patient-reported.

documentation integrity

Ensuring medical records accurately reflect what occurred and are free from improper alterations.

over-documentation

Including excessive or irrelevant detail in medical records that can obscure important information.