Be aware of the pre-formatted templates to a degree...they can be useful but maybe it is best to customized and adapt your own...
Overdocumentation can also be related to how a physician uses an EHR, Martin points out. If a physician implements the system without customizing the EHR templates to his practice style, "the templates may contain more information than what he's used to documenting. So it appears that the history and the exam are more complex, but the medical decision-making level is low."
It's long been known that physicians tend to code higher for office visits after they get EHRs. But now Medicare and private payers are taking an active interest in this trend, and audits of computerized practices are becoming more frequent. So if you have an EHR, be very careful how you code, say coding consultants.
Source: Watch out for EHR audit pitfalls - Coding consultants explain where the risks are and how to avoid them. - Medical Economics
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