CEHRS common mistakes
CEHRS · Understand the traps and how to avoid them.
Writing a note hours or days after the encounter and entering it with the encounter date and time, so the record reads as if it were charted contemporaneously.
Candidates learn 'chart promptly' as a slogan but never drill the mechanics of a late entry, and they assume back-dating makes the record look cleaner for auditors.
What to do instead
Practise the late-entry format until it is automatic: enter the actual current date and time of writing, state in the body that it is a late entry, note the date and time of the original event, give the reason for the delay, and authenticate. Rehearse the sentence 'Late entry for [date/time] encounter because [reason],' then the clinical content.
Fixing a documentation error by typing over the original text, deleting the note, or replacing the page with a 'clean' version.
Word-processing habits carried over from school make overwriting feel like tidying up, and the EHR's edit button makes it technically easy.
What to do instead
Memorise the two-track rule: a correction fixes an error in the original entry (single line through, initial and date, brief reason, correct information added, original still readable); an amendment adds new or clarifying information later without touching the original. Original entries are never deleted or obscured. Practise writing both on paper.
Releasing records on the strength of an authorization that is missing a required core element, such as the patient's signature, a description of the information, the purpose, an expiration date or event, or the statement of the right to revoke.
Candidates skim for the signature and the addressee and stop there, because the core-element list is memorised as a block rather than applied item by item.
What to do instead
Use a fixed six-point checklist every time: (1) description of the information, (2) who may disclose, (3) who may receive, (4) purpose, (5) expiration date or event, (6) signature and date, plus the required notices. If any element is missing, do not release; return it for completion. Note that a valid authorization may permit disclosure for payment or at the patient's request but never obligates it when another rule bars it.
Sending the entire chart when the request names a specific date range, encounter, or set of items, and treating 'the patient asked' as a reason to skip the scope check.
Copying the whole record is faster and feels safer, so minimum-necessary review is skipped under time pressure.
What to do instead
Ask and record three things before copying: who is asking, what exactly is needed, and what is the narrowest set of documents that satisfies it. Limit to the requested dates and document types, note the limitation on the disclosure log, and know the exceptions where the full record is appropriate (for example, a request from the patient for their own record, or treatment purposes where the whole record is clinically needed).
Classifying a patient as 'new' when that patient has been seen within the past three years by a physician of the same specialty in the same group practice, or the reverse, calling an established patient new because the patient is new to that particular clinician.
Candidates confuse 'new to me' with 'new to the practice/specialty' and misread the three-year lookback as a per-provider rule.
What to do instead
Apply a two-step test in order: has the patient received a face-to-face service from any provider of the same specialty in the same group within the past three years? If yes, established for every provider in that specialty in that group. Also confirm the service is one that distinguishes new from established at all; some services never carry a new/established distinction.
Coding from a symptom, sign, or the previous visit's problem list when the provider documented a definitive diagnosis, or listing codes in the order they appear in the note rather than the order the payer requires.
The assessment section is long and the problem list is one click away, so candidates copy the familiar diagnosis instead of reading the current documentation and applying first-listed versus additional-diagnosis rules.
What to do instead
Read the current encounter's assessment and plan, apply the guideline that a condition documented as definite is coded as definite even if the workup is pending, reserve symptom codes for cases where no diagnosis is established, and sequence the code that is chiefly responsible for the encounter first. Verify each code against the index and tabular list rather than memory.
Entering the patient as the subscriber or the subscriber as the patient, or assigning primary and secondary coverage without applying the coordination-of-benefits order.
The registration screen looks nearly identical for the two roles, and candidates assume whichever card is handed over first is primary.
What to do instead
For every coverage, capture the subscriber's name, date of birth, and identifier separately from the patient's, then record the relationship code. Establish primary/secondary with the standard tests (active employee vs dependent, birthday rule for dependent children, Medicare Secondary Payer questions for age, disability, or ESRD) and confirm the order with the payer rather than the card order.
Registering a patient after a surname-only search or by accepting the first plausible match, producing a duplicate record or an overlay of two patients' data.
Registration queues create speed pressure, and candidates treat the search results list as a pick-one menu rather than as candidate records needing confirmation.
What to do instead
Search the master patient index using at least two identifiers in addition to the name, such as date of birth and full street address, and compare every candidate row on name, date of birth, sex, and identifier before selecting. If no match is found, search again with a variation (maiden name, nickname, phonetic) before creating a new record. Practise the duplicate-merge distinction: merge only after verification, and never overwrite an identifier to make a record fit.
Believing a note or order that was deleted, voided, or overwritten in the EHR has disappeared, and being unable to describe what an audit trail must capture.
The user interface shows a clean screen after a delete, so the visible result is mistaken for the actual state of the record.
What to do instead
Learn the audit-trail standard as a list: identification of the user, date and time, the patient record affected, the action taken (view, create, modify, delete, print, disclose), and the original value retained alongside the change. Practise describing a scenario in which a deleted entry remains visible in the log, and remember audit logs themselves are part of the legal record and must be retained and producible.
Pulling a quality or operational report with the wrong population, date range, or field definition, then submitting or acting on the number without checking it against source records.
Candidates trust the report builder's defaults and never learn that report labels often do not mean what they appear to mean, or they choose a data field by its name rather than by its definition.
What to do instead
Before running any report, write down the intended denominator and numerator in plain language, then confirm each filter (encounter type, status, date basis, provider, location) matches it. Validate with a small sample: open five patient records and confirm they meet the definition. Compare the total against an independent count, and document the parameters used so the report can be reproduced.