Q: Ever since we moved to an electronic health record (EHR), our HIM department has noticed some physicians copying and pasting information from previous records. How do we know when this is allowed or when we can query the provider to clarify?
We found out after an observation patient was discharged that one of the procedures performed was an inpatient-only procedure. Can we bill this to Medicare without an official inpatient order on the medical record?
Q: It is my understanding that we can make PHI disclosures using our EHR for payment/treatment/healthcare operations without a consent and that we do not need to track these requests for an accounting of disclosures. Has this changed?
