Health Information Management

Q/A: Will our records pass an audit?

APCs Insider, August 16, 2013

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Q: We have electronic orders submitted from our physician's offices directly into our system. These electronic orders are purged from the system after a set number of days. The vendor told us that these orders could be retrieved should we need to have them for an audit. However, what they can provide is a screenshot of the system entry, but it is not the actual order with the physician authentication. Will this be enough on an audit, since it shows that the order was entered electronically?

A: Electronic physician order entry is a good system for several reasons, including the date and time stamp, legibility, complete and consistent wording on orders, etc. However, like all electronic systems, it has downsides.

CMS has noted that it the provider who is providing the service must be able to produce a complete and authenticated order to support the service provided. While the ordering provider is responsible for producing the order, the provider actually providing the service is responsible for producing the order upon request.

Based on the limited information available, this situation poses a serious concern for being able to support the order for the services. Having a screenshot that an order was entered is not enough to validate the completeness of the order—including physician authentication, which is required on all orders. CMS instructions state that without the physician authentication, the order "shall be" ignored (Transmittals 327 and 465).

Facilities must test and validate all electronic ordering systems—not just initially, but after every update/upgrade and periodically to ensure correct functionality.

Some of the most important functionality is the storage and accessibility of the physician's orders. You should immediately investigate whether this is all orders or a specific subset of orders. Talk with your vendor about any possibilities for retrieving the orders. Also investigate the possibility that the physician office record contains a copy or notation of the order or documentation of the intent of the service.

All facilities should validate the functionality of electronic ordering systems on a regular basis as part of routine due diligence.

Editor’s note: Denise Williams, RN, CPC-H, vice president of revenue integrity services at Health Revenue Assurance Associates, Inc., in Plantation, Fla., answered this question.

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