Electronic medical records have simplified documentation and record tracking. In some cases, the electronic record allows the physician to bring forward, or to “cut-and paste,” previous patient information. Although this may save time, progress notes are critical to support medical necessity.
For example, if an inpatient’s improvement and/or regression is not documented in a dedicated note each day, the payer rightly may question whether services are medically necessary. If the notes do not indicate clearly the reason(s) for the patient’s continued inpatient status, the payer may deny some of the days as medically unnecessary.