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Lynchburg Journal of Medical Science

Lynchburg Journal of Medical Science

Specialty

Hospital Medicine

Advisor

Dr. Elyse Watkins

Abstract

Appropriate application and documentation of a physical exam is vital to the care of patients. Performing and documenting a detailed exam can queue providers into possible ailments or even the acuity of the patient’s disease state. Electronic medical record (EMR) systems are designed to help increase the productivity of the provider by having a check box approach, copying and pasting or “accept default” to a physical exam. This has led to providers to over document physical exam findings and can therefore increase inaccuracies due to the ease of clicking “normal.” The high costs of inpatient hospitalization and the need to maximize reimbursements by meeting Center of Medicare and Medicaid (CMS) guidelines leads hospitalists to over document findings to meet requirements. Over documenting can lead to fraud and ultimately fails both the patient and the provider.

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