Detect The Cloning of EMR| EMR Software in saudi-arabia generate higher level of E & M Codes

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EMR Software in saudi-arabia generated higher level E and M codes than those admitted by the documentation, mainly by including irrelevant information (by default) or sections of the registry that were “cloned” inappropriately (i.e., copied from previous records). And pasted in the current document).


All  Electronic medical record software in saudi-arabia have the ability to “clone” information from other areas of the registry, but none that I have worked with gave any warning that a section of the record has been copied and may contain inaccurate information. Auditors, like me, are now using anti-plagiarism software and other methods to detect the cloning of electronic medical records. One of the biggest problems of the cloned note is the lack of updating from one encounter to another.

Most common EMR problems:

Although the characteristics of each EHR registration system vary, some of the problems, based on my experience with numerous E-Clinic Software in saudi-arabia and the audited registry, that have impacted the coding are the following:

1. Programming Errors

  • Inaccurate service calculation levels (E and M codes) based on information documented in the record.
  • Inaccurate and misleading representation of terminology and concepts related to coding, despite an established adherence to the published guidelines of the Centers for Medicare and Medicaid Services (CMS).


2. Usability problems

  • Doctors complain that the EMR is difficult to use and their EMR tools to select the correct E and M code during the patient encounter decrease the time the doctor wants to be face to face with the patient, without looking down on a screen.
  • Highly complex software applications make it difficult for users to modify the way Hospital management software in saudi-arabia recognizes and manages E & M coding information. For example, it was difficult for users to create content and set system default values ​​relevant to E-. coding and M.

3. Education and training were also at stake

  • Inadequate staff training for best coding practices when using your particular EMR system.
  • Lack of supporting documentation that explains how systems determine E & M codes, further aggravating the above problem.
  • The user is not familiar with E & M coding guidelines, which worries me since the 1995 and 1997 guidelines are now more than 20 years old and have only changed slightly over the years.


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