HCA 417 Electronic Health Record EXPERIENCE IN EHR ONLY

The Importance of Clinical Documentation

What is the outcome when a clinical auditor is reviewing E&M code calculations and the unethical and illegal pitfalls of up-coding by means that contradict regulatory guidelines?  

In 250-300 words, discuss how and why a physician and medical coder should adhere to the coding conventions, official coding guidelines, rules and assigned codes that are clearly supported by clinical documentation in the health record.

 Include examples of where this can occur so a physician or entity, maximize their payments and the ramifications if discovered in a clinical documentation audit? 

Advantages and Disadvantages of Data Entry into the Electronic Health Record

In 250-300 words discuss how you ensure that the medical staff enters the entire data in the Electronic Health Record and ensure they understand the effect the EHR has on the patient and the provider.

Is it more advantageous to have the patient enter their own symptoms and history into the EHR since they are the only one with the information about the symptoms that were present at the outset of the illness, or is it more advantageous for a licensed clinician to enter the patient information data?

 What would be the advantages and disadvantages of the patient entering vs. a health care professional in just the history portion of the EHR?

Text for the assignement is as follows:

Gartee, R. (2011).  Electronic Health Records (2nd ed.).  Upper Saddle River, NJ:  Pearson Prentice Hall.

Only use references that exist between 2010 thru 2014.