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Pathology/Lab Coding Alert

Medical Record:
Master Documentation Tips and Pitfalls

Use cut and paste judiciously. You may love the timesaving features of electronic health (medical) records (EHR or EMR), but the convenience can backfire if your reports start looking like rubber stamps. Payers are on the lookout for cloned notes or health records that are overly similar (or exactly similar) among patients and reports. “It’s becoming an issue that you [...]