• Justin M Weis and Paul C Levy.
• Chest. 2014 Mar 1; 145 (3): 632-8.

AbstractThe modern medical record is not only used by providers to record nuances of patient care, but also is a document that must withstand the scrutiny of insurance payers and legal review. Medical documentation has evolved with the rapid growth in the use of electronic health records (EHRs). The medical software industry has created new tools and more efficient ways to document patient care encounters and record results of diagnostic testing. While these techniques have resulted in efficiencies and improvements in patient care and provider documentation, they have also created a host of new problems, including authorship attribution, data integrity, and regulatory concerns over the accuracy and medical necessity of billed services. Policies to guide provider documentation in EHRs have been developed by institutions and payers with the goal of reducing patient care risks as well as preventing fraud and abuse. In this article, we describe the major content-importing technologies that are commonly used in EHR documentation as well as the benefits and risks associated with their use. We have also reviewed a number of institutional policies and offer some best practice recommendations.

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