Lecture 2: Electronic Health Record

Question 1

“Meaningful use” (MU) refers to the use of certified EHR technologies by health care providers in ways that?

Answer 1

Measurably improve health care quality and efficiency

Question 2

What are the recent changes in Centers for Medicare and Medicaid Services policies on medical student documentation in the clinical setting?

Answer 2

• Teaching doc can verify in the medical record ANY student documentation of components of E/M services, RATHER than re-documenting
• Student may document in the medical record. However, the teaching doc must verify in the medical record ALL student documentation or findings, including hx, PE and/or medical decision making
• Teaching doc must personally perform (or re-perform) the PE and medical decision making activities of the E/M service being billed, but may verify any student documentation of them in the medical record, rather than re-documenting