What should be checked in E/M documentation when using EMR/EHR?

In the context of E/M documentation using EMR/EHR, it is crucial to check that records have not been cloned. Cloning refers to the practice of copying and pasting previous documentation into new entries without proper review or modification. This practice can lead to inaccurate or misleading representations of a patient's current condition, as it might not reflect changes in the patient's health or treatment plan over time.

Ensuring that records have not been cloned helps maintain the integrity and accuracy of clinical documentation. It guarantees that each patient encounter is unique and that the information recorded is a true reflection of the patient's current health status, including any updates or changes in their treatment. This is vital for ensuring proper coding and billing, as well as for providing appropriate patient care.

Checking for cloning is part of a broader effort to promote high-quality, compliant documentation practices, which is essential for both the medical auditor and the healthcare provider to ensure that documentation meets legal and regulatory standards.