documenting patient communications underwent some tweaking before tak- ing on its final form, which requires physicians to document any com- munication the doctor transmits or receives about which “a medical deci- sion is made regarding the patient.” TMA was more supportive of the
eventually adopted language. Dr. Murray says the final rule’s re-
quirement that physicians document communications with patients that involve medical decisionmaking is sensible.
“The concern was over the possibil- ity that physicians would be required to record every conversation with a patient, which would be burdensome and really wouldn’t add to either the quality of care or to the accuracy of the medical record,” he said. “So with that discussion, we were able to at least narrow the communications down to those that impacted decisions made on patient care, and it is reason- able to include those in the medical record.” To address the concern of EHR fields being improperly pre-populated, TMB adopted a new subsection in the rule that states, “All non-biographical populated fields, contained in a pa- tient’s electronic medical record, must contain accurate data and information pertaining to the patient based on ac- tual findings, assessments, evaluations, diagnostics or assessments as docu- mented by the physician.” TMB Executive Director Mari Rob-
inson explains the board began to see instances of EHR computer systems that were pre-populating test results as normal, even when the tests or eval- uations hadn’t been performed. “So the board wanted to make very clear that the only type of things that should be pre-populated are things like name, date of birth, that type of information,” Ms. Robinson said, “ver- sus this idea of pre-populating an out- come of an evaluation or a test when that has yet to be completed.” TMB adopted the non-biographical populated fields rule provision despite
Why Is TMA Membership Important to Me?
Because only a strong, unified physician voice can shape an environment that supports the practice of medicine.
TMA fights to ensure physicians are in charge of medicine.
We deliver advocacy, knowledge, and resources to help you, your practice, and your patients. Join TMA today at
join.texmed.org.
Questions? Call the TMA Knowledge Center at (800) 880-7955.
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We provide marketing reps for your practice. Contact us today to learn how we can help increase your new patient referrals.
www.lexiconmedical.com (855)MED-REPS July 2015 TEXAS MEDICINE 55
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