Electronic signatures, self-populating entries, retrospective self-populating entries and customization are the four most common compliance issues for organizations utilizing electronic health record (EHR) software.
“One hundred percent of provider’s service notes or healthcare records could be noncompliant, based on the underlying software, and the provider would never know,” wrote RACmonitor. “If the provider is accused of failing to report a $1 million overpayment based on a flaw in the software, who bears the burden? The provider? Or the noncompliant software company?”
The most common compliance issues for EHR use include:
- Electronic signatures – Providing the healthcare providers name with service notes is not compliant with Medicare criteria.
- Self-populating entries – Inconsistencies in notes and medical records present liability issues to auditors.
- Retrospective self-populating entries – Certain EHR software’s populate information pro- and retrospectively, creating a risk for providers.
- Customization to a specialty – The software template may include information not relevant to certain providers.