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It covers issues such as over-documenting, corrections, cloned notes, patient involvement, valid records, stolen or missing data, coding errors, and workflow distortions caused by templates and software shortcuts. It also discusses EMR/electronic coding combinations that detect missing or invalid data and suggest corrections, while noting integrity and billing concerns.",{"@graph":69,"@context":114},[70,84,105],{"@type":71,"itemListElement":72},"BreadcrumbList",[73,77,79,82],{"item":74,"name":75,"@type":76,"position":8},"https://docshare.wps.com","Home","ListItem",{"item":78,"name":9,"@type":76,"position":14},"https://docshare.wps.com/document/",{"item":80,"name":35,"@type":76,"position":81},"https://docshare.wps.com/document/healthcare/",3,{"item":83,"name":65,"@type":76,"position":19},"https://docshare.wps.com/document/coding-strategies-coding-strategies-em-coding-strategies/388172/",{"url":83,"name":65,"@type":85,"image":86,"author":91,"headline":65,"publisher":94,"fileFormat":97,"inLanguage":63,"description":67,"dateModified":98,"datePublished":99,"encodingFormat":97,"isAccessibleForFree":100,"interactionStatistic":101},"DigitalDocument",{"url":87,"@type":88,"width":89,"height":90},"https://docshare.wps.com/thumbnails/coding-strategies-coding-strategies-em-coding-strategies/388172.png","ImageObject",300,407,{"name":92,"@type":93},"Sarah ","Person",{"url":74,"name":95,"@type":96},"DocShare","Organization","application/pdf","2026-10-29","2026-09-25",true,{"@type":102,"interactionType":103,"userInteractionCount":14},"InteractionCounter",{"@type":104},"ViewAction",{"@type":106,"mainEntity":107},"FAQPage",[108],{"name":109,"@type":110,"acceptedAnswer":111},"What correction principles are recommended for erroneous medical record entries?","Question",{"text":112,"@type":113},"The material advises against using pencil or red pen and against obliterating incorrect passages. It recommends drawing a single line to keep original data legible, signing and dating the deletion with the reason, documenting the correct information, and tracking the original entry and the correction with date, time, and identity of the individual making the change.","Answer","https://schema.org",{"og:url":83,"og:type":116,"og:title":65,"og:site_name":95,"og:description":67},"article",{"robots":118,"canonical":83},"index,follow",{"doc_id":120,"site_id":62},388172,1790748912,{"code":4,"msg":5,"data":123},{"doc_id":120,"user_id":124,"nickname":92,"user_avatar":125,"doc_module":4,"category_id":34,"category_name":35,"doc_title":65,"doc_description":67,"doc_content":126,"file_id":127,"file_url":128,"file_type":129,"file_size":130,"view_count":14,"is_deleted":4,"is_public":8,"is_downloadable":8,"audit_status":8,"page_count":131,"language":132,"language_code":63,"site_id":62,"html_lang":63,"table_of_contents":133,"faqs":134,"seo_title":135,"seo_description":67,"update_tm":136,"read_time":137,"preview_page_count":4},962085320529,"https://ap-avatar.wpscdn.com/davatar_9964176cb1d06d4a9deccf72a44ae3dc","1/21/2011  \nCindy C. Parman, CPC, CPC‐H Coding Strategies, Inc. [www.codingstrategies.com](www.codingstrategies.com)  \n\n| \u003Cbr>| The format and/or content of this presentation is copyright © 2011 by Coding Strategies, Inc.(CSI), Powder Springs, GA.\u003Cbr>This handout was created to accompany a verbal presentation and may not have value in the absence of the complete presentation material. |\n| --- | --- |\n| Copyright 2011 CSI\u003Cbr>2 |  |\n\n\n| \u003Cbr>􀁹 Introduction\u003Cbr>1. Compliant E/M\u003Cbr>2. Over Documenting\u003Cbr>3. Corrections\u003Cbr>4. Cloned Notes\u003Cbr>5. Patient Involvement\u003Cbr>6. Valid Record\u003Cbr>7. Stolen Data\u003Cbr>􀁹 Final Thoughts | |\n| --- | --- |\n| Copyright CSI 2011 |  |\n\n1/21/2011  \nCERT  \n  Illegible signatures/dates  \n Other errors  \n Missing documentation  \n Insufficient documentation  \nCopyright CSI 2011  \nCERT  \nMissing/ incomplete doc  \n Incorrect codes  \n Other errors  \nCopyright CSI 2011  \n\n| | |\n| --- | --- |\n| Copyright CSI 2011 |  |\n\n2  \n1/21/2011  \n\n| Whether a manual or electronic health record is maintained, there is still a need to ensure that the information generated by the healthcare provider is accurate, timely and available when needed. | |\n| --- | --- |\n| Copyright CSI 2011 |  |\n\n􀁹 Software systems may allow submission of non‐ compliant or potentially fraudulent E/M claims  \n􀁹 May document a higher level than medically necessary  \n􀁹 May have shortcuts that create documents automatically  \n􀁹 Could result in distorted workflow  \n􀁹 Or questionable data integrity  \nCopyright CSI 2011  \n\n| | Coding Engines\u003Cbr>􀁹 May code visit level solely based on history and examination\u003Cbr>􀁹 May fail to consider medical necessity |\n| --- | --- |\n| Copyright CSI 2011 |  |\n\n1/21/2011  \n\n| \u003Cbr>| All encounters may default to comprehensive history and examination\u003Cbr>􀁹 Regardless of chief complaint\u003Cbr>􀁹 Or presenting problem\u003Cbr>􀁹 Or visit frequency\u003Cbr>􀁹 Identical vital signs\u003Cbr>􀁹 Identical diagnosis |\n| --- | --- |\n| Copyright CSI 2011 |  |\n\n\n| | 􀁹 EMRs cut physician‐patient time\u003Cbr>􀁹 Doctors don’t look patient in the eye\u003Cbr>􀁹 Decreased patient satisfaction?\u003Cbr>􀁹 Restructure exam room? |\n| --- | --- |\n| Copyright CSI 2011 |  |\n\n􀁹 A hospital EMR/electronic coding combination:  \n􀁹 Recognizes when data is missing or invalid  \n􀁹 Suggests correct data  \n􀁹 Detects “coding errors” (non‐covered diagnoses)  \n􀁹 Suggests correct codes to ensure payment  \n􀁹 Automatically “loads” charges for supplies  \n􀁹 May double bill for these items  \n􀁹 But, results in fewer rejections!  \nCopyright CSI 2011  \n1/21/2011  \n\n| | |\n| --- | --- |\n| Copyright CSI 2011 |  |\n\nIf the electronic template selected does not conform with either the medical condition of the patient or the service provided by the physician, an inappropriate code will be generated. Thus, for physician practices that utilize an electronic medical record, the review and monitoring program must include the ability to determine whether the template description of the service provided or medical condition of the patient as selected by the physician is accurate.  \nCopyright CSI 2011  \n\n| Notes that should be focused may become voluminous and templated\u003Cbr>|  |  |\n| --- | --- | --- |\n| 􀁹\u003Cbr>􀁹 | Not a product of clinical thinking Distracts from providing care | |\n| Copyright CSI 2011 |  |  |\n\n1/21/2011  \n\n| Physician may have to search through repetitious notes for a single line that documents a new medical condition.\u003Cbr>| |\n| --- | --- |\n| Copyright CSI 2011 |  |\n\n􀁹 “Normal” may have different meanings  \n􀁹 Exploding notes  \n􀁹 Verifying author  \n􀁹 Patient‐completed documents  \n􀁹 Informed consent  \nCopyright CSI 2011  \n\n| 􀁹 Pattern of coding may change with implementation of EMR\u003Cbr>􀁹 EMR documentation may not match codes\u003Cbr>| |\n| --- | --- |\n| Copyright CSI 2011 |  |\n\n1/21/2011  \n􀁹 96% of physicians concerned “about losing the unique patient story” with the transition to point‐and‐click (template driven) EHRs  \n􀁹 94% said that including the physician narrative as part of the medical record is “important” or “very ","cbCaiuCFQ0EoaoxX","https://ap.wps.com/l/cbCaiuCFQ0EoaoxX","pdf",3531971,23,"English","# Introduction\n## Compliant E/M\n## Over-documenting\n## Corrections\n## Cloned Notes\n## Patient Involvement\n## Valid Record\n## Stolen Data\n# Final Thoughts\n## CERT (signature, documentation, codes, other errors)\n## Template-driven coding risks and detection","[{\"question\":\"What correction principles are recommended for erroneous medical record entries?\",\"answer\":\"The material advises against using pencil or red pen and against obliterating incorrect passages. It recommends drawing a single line to keep original data legible, signing and dating the deletion with the reason, documenting the correct information, and tracking the original entry and the correction with date, time, and identity of the individual making the change.\"}]","Coding Strategies - Coding Strategies E/M Coding Strategies | PDF",1790295112,58]