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My question is, Can you open an office note the day before and pre load for the next day? In other words, open a note the day before and then the next day when you chart you can change the date?
Thank you
Julie A. LaRossa
Posted : August 10, 2017 2:53 am
You can't through Centricity. I have made a program to allow this though.
https://marketplace.centricityusers.com/#/my-account/preview/475
Posted : August 10, 2017 3:27 am
You can, but only if there are no signed clinic list changes within that visit. Once there are clinical list changes, you cannot change the date of service.
Posted : August 10, 2017 4:08 am
There is a reason Centricity does not permit this.
What you are asking for, if I understand it correctly, is to 'pre-load' the visit the day before the patient arrives, then alter the date to the date of the visit.
I strongly recommend that you first discuss this workflow with your organizations legal counsel. I believe that all states and federal statutes as well as payers prohibit it. Even if your state does not have a specific law against it, it is not in compliance with Standards of Care set forth by licensing agencies, State Boards, and Professional Organizations (i.e AAFP, MGMA, etc.).
In my 30 years of clinical experience, I cannot recall a single case where this was NOT considered fraud as well as being extremely difficult to defend in court. If found in an audit, your provider could be writing a huge refund check back to the insurer at the very least.
You can, however, document the day before as long as each entry is clearly identified as being documented the day before. Understand, however, that some or all of that work may not qualify for billing purposes since it was not done at the actual time of the visit (resulting in a reduced billing level). For clarity, consult the payers for more accurate details.
As I posted elsewhere, I urge all who work with the EMR to become familiar with the law. Just because it 'can be done' does not always mean it is a good idea. Understand that forensic examination of EMRs is a growing industry for malpractice investigations. In 2015 both Cerner and Epic were named in legal claims that their EHRs caused patient harm. Those suits are ongoing and their outcomes will set precedent for case law in the future.
Change is coming and it will involve including previously 'immune' job descriptions in the liability profile of each organization.
A bit dated, but still a wise read:
http://www.healthcareitnews.com/news/emrs-can-be-costly-malpractice-suits
Also, dated, but on topic:
http://www.medscape.com/viewarticle/828403_4
Many EHRs are touted as being highly customizable, and many doctors purchase an EHR with the idea of tinkering and tweaking to get it just right for their practices. And most EHRs can indeed be customized -- if you know what you're doing. If you don't, and you get sued, it could harm you in court.
"'Customization' means different things, depending on the product you're using," says Sterling, the EHR consultant. "Some products actually allow me to go in and change the nature of the product so it isn't doing what it was supposed to do as advertised, and/or I use the product in a nonstandard way, so it doesn't do what it's supposed to be doing. If you're not using it in a way that maintains patient information in a reliable way, you could run into a problem."
Posted : August 10, 2017 4:24 am
Have you ever dealt with Joint Commission? I would not want to open my organization up to the audit you are asking for in doing this. If preloading is all you are wanting, then just use a preload encounter type. Then when the patient arrives for appt start your visit, reconcile the information and go from there.
Posted : August 10, 2017 6:20 am
