• Operative Report Storage

    Question: Our surgical operative reports are kept in the electronic health record (EHR) system of the facility, not our practice. We have access to this EHR as we are under the same taxpayer identification number (TIN). Do we have to have a copy of the operative report in our patient chart for the practice in case we are audited?

    Answer: Since you have direct access and haveare the same tax ID number, it should be acceptable. If you were separate businesses, the recommendation would be to is storeing a copy in your EHREHR, as you may run into an issue of not being allowed access in the event of an audit. Be sure those who are preparing documentation for an audit know where all content is located.

    Learn more about documentation in the Learn to Code the Essentials.