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When a physician copies and pastes and fails to ensure the accuracy of the documentation, it not only is inaccurate and may inflate the level of service but could also jeopardize patient care. The other problem with the copy-paste function in the EHR is that if the physician does not change the documentation for the patient visit or changes very little, it gives the illusion of cloning. That can be problematic, as an auditor would either question or disallow this information from being included in the level of service. Many times when the provider pulls information into the documentation from a previous visit, it might not be relevant to the reason for the visit or care. This can be referred to as "overdocumenting," the purpose of which is to create an appearance that supports billing a higher level of service. I would recommend that you share with the providers the Office of the Inspector General's (OIG) whitepaper "CMS and Its Contractors Have Adopted Few Program Integrity Practices to Address Vulnerabilities in EHRs." One of the more problematic issues is generating or pulling in other documentation that might not be relevant to the patient encounter. Providers who use clicks only to pull in information are more vulnerable than the provider who actually creates the majority of the note. All templates should make sense for the provider while maintaining compliance. Many practices use the EHR's templates built into the system but never customize them for the practice, which should be discouraged.
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Many times the templates need to be reviewed and changed to discourage this practice and allow for more free text instead of clicking information and pulling it into the patient encounter. Some are using smart text or pulling in phrases that might not be appropriate for the particular patient. Most physicians are using the EHR by pulling in information and copy-pasting. I would appreciate knowing whether other organizations are experiencing this in the hospital setting.
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Do you have any guidance or suggestions as to how to discourage this practice? Our Medicare contractor posted that rather than randomly pulling dates of service for review, a new process implemented has several successive dates of service reviewed. A provider uses this functionality (copy-paste) quite regularly, including repeating the radiology interpretation which can sometimes be several pages depending upon the number and type of tests, eg, CT, X-ray, ultrasound. Often the exam is completed with the same documentation repeated. Since the implementation of an EMR in our organization, it has become evident through documentation reviews that subsequent progress notes are being carried forward for several days of service with only a few extra words inserted for changes in plan. Ask the Experts: Documentation, Coding Issues Abound