Coding leaders know that a coding or documentation audit is not the end of the audit process, it’s the first step towards implementing meaningful operational enhancements. Audit findings can reveal more than isolated documentation errors, they often uncover deeper systemic EHR template issues.
When EHR templates are inefficient or obsolete, even the most diligent providers and coders struggle to document accurately. Identifying and correcting template issues after an audit can reduce compliance risk, improve coding accuracy, and increase both operational and financial performance.
The Connection Between Audits and EHR Templates
Health systems uses audits to ensure compliance and accuracy. Common audits include:
- New Provider Audits
- Annual Compliance Provider Audits
- Coder Audits (Internal or Vendor)
- Department-Specific Audits (Family Medicine, Surgery, etc.)
- Focused Audits
- HCC and Telehealth Reviews
- ED Facility or Infusion Audits
- Annual OIG or CDI Audits
- Re-Audits of High-Priority Areas
Each audit produces a report detailing scores, financial impact, payer mix, and specific findings at the encounter level.
These reports typically roll up into an Executive Summary, which summarizes issues and recommendations in terms that operational and administrative leaders can understand. Executive summaries are valuable because they highlight high-risk areas and potential revenue loss. Many of the issues listed in these summaries often originate from EHR template insufficiencies such as missing documentation fields, incorrect note headers, or hardcoded codes.
A best practice is to track these findings in a Compliance Tracker. The tracker can document issues, progress, and completion, providing a clear path from audit finding to resolution. When used effectively, this tool transforms audit results into actionable improvement plans, including those focused on EHR repair.
Common EHR Template Issues
EHR templates are intended to streamline documentation, but they can also introduce risk when not properly designed or maintained.
Common problems include:
- Overuse of copy and paste
- Auto-populated or pre-set negative responses
- Lack of clinical specificity
- Non-customizable or rigid templates
- No free-text option for nuanced documentation
- Overuse of smart phrases or canned text
- Contradictory or duplicative documentation
- Missing or inaccurate note headers
- Hardcoded CPT or ICD-10 codes within templates
- Absence of templates for common services
The Operational Cost
Poorly built EHR templates create inefficiency across multiple departments. Providers lose time searching for the right fields or correcting errors, which takes attention away from patient care. Coders and billers spend additional hours reviewing, querying, or reworking encounters. These repetitive tasks delay claim submission and increase administrative workload across the revenue cycle.
The solution begins with a structured plan that unites compliance, clinical, and technical stakeholders to correct template issues and rebuild processes that work for everyone.
Developing a Cross-Functional Plan to Execute EHR Repairs (Our Proven 7-Step Process)
Improving EHR templates requires a coordinated, step-by-step approach that involves multiple teams. The following seven-step framework helps HIM leadership turn audit findings into sustainable EHR improvements.
Step 1: Develop an Action Plan and Tracker
Start by reviewing audit and Executive Summary findings to identify template-related issues. Present the business case to stakeholders such as Compliance, HIM, IT, Clinical Leadership, and Billing. Develop a clear plan that defines owners, deadlines, and deliverables. Maintain a single shared tracker to document progress and ensure accountability.
Step 2: Gather Information
Perform a full inventory of templates across all service lines, including E/M visits, preventive care, chronic care management, operative notes, and orders. Review tools such as smart sets, smart phrases, canned text, and any hardcoded charge capture functions. Understanding how each template is used and how information flows through it is key before making any changes.
Step 3: Implementation
Clarify who is responsible for making and approving template changes. In most organizations, IT manages builds and updates, while HIM, Compliance, and Provider leadership review content for accuracy and usability. Work directly with IT to review templates as providers see them, not just the finalized view available to auditors. This may include reviewing blank templates, dropdown menus, and required fields.
Step 4: Testing
Always test changes in a non-production or test environment. Assign both clinical users and HIM reviewers to test documentation flow and coding outcomes. Confirm that updates function correctly and support compliant, complete documentation before go-live.
Step 5: Training and Follow-Up
Once testing is complete, communicate updates to all end users. Send concise update summaries, hold brief training sessions, and confirm attendance. Schedule follow-up reviews after go-live to ensure templates function as intended and address any additional user feedback promptly.
Step 6: Track Results
Use your Compliance Tracker to document all progress and outcomes. Report results to leadership regularly, highlighting measurable improvements in accuracy, audit scores, and efficiency. Optimized EHR templates often lead to fewer denials, improved coder productivity, and better provider satisfaction.
Step 7: Close the Loop
After changes are implemented, complete all necessary follow-up steps. This may include correcting claims, processing insurance paybacks, or conducting re-audits to validate that changes resolved the original issues. Communicate results to all departments involved and close items formally in the tracker.
Conclusion
Audits provide essential insight into where documentation and coding breakdowns occur. The most effective leaders use these insights to improve underlying systems rather than treating each issue in isolation.
Correcting and optimizing EHR templates creates a lasting impact that extends beyond compliance. It strengthens documentation quality, reduces administrative burden, and helps ensure accurate reimbursement. The result is a more efficient, compliant, and high-performing organization.
To learn more about scheduling a coding audit, please contact us here.
