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Discussion

Documentation and EMR

I have a few questions regarding documentation and diagnosis codes. The practice I work for has us making changes to medical records that I feel may be inappropriate.

Our software has two places it holds the problem list and the medical history. The medical history transfers from note to note. The problem list updates as people are diagnosed. My practice wants us to make the medical history and the problem list match, so they have us deleting information off of both lists. They want only chronic problems on both lists. I feel that we, as nurses, are making decisions as to what is a chronic problem and what is an acute problem and then effectively altering the medical record by deleting information.

The second thing they want us to do is to change diagnosis codes. For example if a provider diagnoses someone with code 401.9 Unspecified Essential Hypertension, they want us to change it to 401.9 Essential Hypertension. They don't want any diagnosis in the system that say "other", "unspecified", etc. I feel we are changing a Dr. diagnosis by doing this.

Any advise would be greatly appreciated. Thanks!

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    I'm always leery of institutional practices that take away medical diagnosis and decision-making away from licensed providers in order to capture a higher reimbursement from insurance companies. I think you have reason to feel concerned. What I would suggest (and this is assuming you are a coder/biller) is that you discuss alternative plans of resolving issues with your team other than arbitrarily altering patient problem lists as you are doing currently.

    I work in hospital settings as an NP and what usually is done where I've worked is that coders send messages to providers such as myself to suggest considering making accurate diagnoses that match the patient and maximize revenue generation. It's not fraud because we don't make up diagnoses that aren't there but it helps to get the coders perspective as to how to best capture the actual revenue we would have missed had we not been aware of these slight differences.

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    That is part of my concern. None of the nurses are coder/biller. Alternative suggestions have been made and they won't hear it. So now I feel like we are in a position where if we don't make the changes our jobs could be in jeopardy. I am concerned about the ethical stuff involving deleting medical history.

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    If your system tracks all users, when an audit is done, it will show that the nurses changed the diagnoses, thus leaving YOU open for possible sanctions. Some EMR systems do not give anyone access to the problem list other than the provider. Has policy been updated to incorporate what is and is not allowed with your EMR system? Take your concerns to the office manager. You need to CYA. Good luck.

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