Question

Acme Physician Practice has purchased a new system that assists providers in creating patient notes and billing encounters from some basic input information. The physicians are excited because the system allows them to create a good note and then use it to paste into other encounters and edit. The billing manager is excited and the entire office is happy about this discovery. As the HIM professional, what is the most appropriate response?

Answer 1

As HIM professional, the response is not in favour of the system.The system may create few problems to the safety and security of the patients.

• The system has an option of creating a note and can copy paste to any encounter needed.Well this is good but here, there may be chance of mispasting the information in other encounters which does not belong to the particular patient.
• Also there is a chance of editing the information of pasting.Well this good to make changes but, there is a chance of making fraud by any one to change the information.
• Instead it should be in another way like when a person had opened the particular encounter , this encounter can be edited copied or pasted only by that particular authorized one.
• Creating a note is good , but it should have featured of accepting copy or paste only if the encounter and patient information matches to avoid breach.