PROGRESS NOTES: Copy and Paste with Caution

PROGRESS NOTES: Copy and Paste with Caution

  • 18 Dec Off
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By Richard Schamp, MD
Chief Executive Officer

Our service to clients involves reading encounter notes for coding, auditing and training purposes.  We read A LOT of notes.  Sometimes we see portions of notes that are strikingly similar to previous documentation.  Copy/pasting, also known as cloning, enables users to select information from one source and replicate it in another location. When doctors, nurses, or other clinicians copy/paste information but fail to update it or ensure accuracy, inaccurate information may enter the patient’s medical record and inappropriate charges may be billed to patients and third-party health care payers. Furthermore, inappropriate copy-pasting could facilitate attempts to inflate documentation and generate payments that could be considered fraudulent. 

Richard Schamp, M.D.
Chief Executive Officer

Some EHR systems can carry forward or copy/paste a previous exam or history. This can be a time-saver, but such features or templates may also result in documentation errors if documentation items are pulled forward that aren’t actually performed, or if the provider doesn’t update a result that may have changed, e.g., been positive at a previous visit, but is negative for the current visit.

The Centers for Medicare & Medicaid Services website has an Electronic Records Toolkit that addresses specific concerns and violations regarding note cloning, as well as the definitions of these.

CMS acknowledges “Some EHR systems use templates that complete forms by checking a box, macros that fill in information by typing a key word, or functions that auto-populate un-entered text. Problems can occur if the structure of the note is not a good clinical fit and does not accurately reflect the patient’s condition and services. These features may encourage over-documentation to meet reimbursement requirements even when services are not medically necessary or never delivered.”

 Office of Inspector General (HHS-OIG) indicated that due to the growing problem of cloning, its staff would be paying close attention to EHR cloning.

Published guidance on use of EHR technology remains just that, guidance.  It might be summed up as … “The medical record must contain documentation showing the differences and the needs of the patient for each visit or encounter.”  Consequently, we urge our clients to have internal policies that address the appropriate use of technology such as copy/paste, macros, templates and other features that create risk for compliance.  Such policies should provide a solid base for provider accountability, so we recommend associated processes for internal auditing and monitoring.   

The goal is to embrace any advantages of electronic documentation but to avoid abuse.