Electronic health records (EHRs) have great potential for capturing important health information and making that information readily available to providers of care—so much so that the Centers for Medicare & Medicaid Services (CMS) EHR Incentive Programs have paid incentives to more than 500,000 physicians, hospitals, and other eligible providers for meeting meaningful use criteria. However, controversy abounds regarding the current features and use of EHRs. An important consideration as physicians and providers enter information into an EHR is what do others who read this record see? The output of EHR documentation is not only paramount to continuity of care but also must support the quality of care provided, medical necessity of services rendered, and accuracy of services billed.

The CMS has noted increased concern about the potential for fraud, waste, and abuse and the loss of documentation integrity that could compromise patient care when EHR documentation standards are not adopted...

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