1.
Entries carried forward from a previous visit(s) must be reviewed for accuracy and edited appropriately. Be sure system phrases represent what happened in ‘today’s’ visit and clinical data that was not done in ‘today’s’ visit
is clearly indicated. It is not appropriate to carry forward information if it is not pertinent to the date of service rendered.
2.
Be sure the History of Present Illness (HPI) and Review of Systems (ROS) agree when using templates/SmartPhrases and checkboxes to generate Review of System documentation.
3.
Do not use templates to pre-populate entire Review of Systems or Exam sections with “canned” negative
findings. Fields should be populated by checking a box, selecting from macros and templated documentation, typing freetext, or selecting from a drop down menu.
4.
Capturing pertinent visit data is essential when utilizing template tools.
5.
“Mark as Reviewed” are checkboxes that occur throughout Epic applications, and phrases like “I have updated/confirmed the history” can be found in templates. When you click on “Mark as Reviewed,” it indicates that you reviewed that section of the patient’s chart. It also means “I have confirmed this documentation with
the patient/patient’s family”. “Mark as Reviewed” does not transfer the ownership of that note. THE TEACHING
PHYSICIAN IS REQUIRED TO DOCUMENT A PERSONAL NOTE.
6.
“Make me the Author” (MMTA) - is a copy forward function that changes note authorship to your name. A copy of the original note and author is retained and is readily available in the EPIC audit trail by clicking “Previous
Version”. If using MMTA, a teaching physician (TP) must document a personal note that supports that they saw and evaluated the patient and describes their role in the plan. It is insufficient for the TP to edit a resident/ fellow note without adding personal documentation to support their presence in the key and critical portions of the service.
7.
Do not copy/use any portion of a medical students note other than Review of Systems (ROS) and
Past/Family/Social History (PFSH). Federal regulations are clear that only the portion of a note originally
authored by a medical student that can be used in support of a bill are the ROS and PFSH sections of History.
8.
Do not copy documentation from another author without proper notation and attribution to the original
author. This must include reference to the date, time and author of the original entry.
9.
Notes must reflect all practitioners’ services. When you combine a note with a resident’s, the medical record must be able to identify that you saw and evaluated the patient, that you reviewed the note, and include patient specific information provided by you. When you combine a note with a Non-Physician Practitioner (NPP) (e.g., PA,
APRN), the documentation must reflect the participation and contribution of each practitioner. Teaching physician attestations do not apply to NPPs.
Yale Medical Group Compliance Department November 12, 2012 1

10.
Check your printed notes. The information as viewed while on line in the Epic environment may look considerably different than the printed record. It is this printed note that will be provided to outside users such as payors, federal and state agencies to support your service.
11.
You are responsible for the review/comment on any lab results and other studies imported into your note via any means (template/copy functionality). Delete those that are not pertinent or not medically necessary to the documented visit.
12.
Just as is the case with paper records, when billing based on time, do not combine time with resident’s or
APRN’s/PA’s. When utilizing time as the key factor in qualifying for a particular level of evaluation and management service (E&M) be sure to include the total time, that more than 50% of the time spent was in counseling and/or coordination of care, and that the extent of counseling and/or coordination of care (i.e. topics discussed with the patient or patient’s family) are documented.
13.
No chart-to-chart copying between patients.
14.
Do not rely on E&M level guidance provided by Epic Ambulatory. Level of Service guides in Epic use the 1997
General Multi-System Exam guidelines only, while 1995 Physical Exam guidelines may be more advantageous.
15.
Confirm the Patient history dropped into your note via SmartLinks. Many notes open and automatically populate your physician note with past, family, social history that is already in the medical record from previous encounters, and may be information gathered by a nurse. You must state in your note that you have reviewed
the information with the patient/patient’s family.
16.
The patient problem list is only maintained in the problem list section. When using templates that import the problem list into your physician note, keep in mind the link only flows one way. If you identify a new problem and include it only in your note, it does not flow back to be included on the central/shared problem list. Therefore, please include it on the central/shared problem list. Links into your note can be refreshed to update the problem list in your note once you have updated the central problem list.
17.
Templates utilized in EPIC will need to meet Centers for Medicaid & Medicare Services (CMS) guidelines for evaluation & management services (E&M) and Teaching Physician Rules.
18.
It is not the recommended practice to use “Select All” when associating diagnosis codes to the CPT codes for the encounter.
19.
It is recommended that your department or PFS clinical practice specialist review any templates or blocks of smart texts to insure compliance with documentation requirements for E&Ms and teaching physician guidelines.
In Summary: You are responsible for the entire content of your documentation.
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