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Shortcuts in Electronic Records Pose Risk by Chris Dimick Electronic documentation habits such as copy and paste save valuable time, but they can ruin the record.
Past notes were being electronically copied and pasted into current records.
Old services rendered were being documented over and over again, with additions to reflect any new services. This specific scenario is only an illustration, but documentation auditors say they see similar practices occurring. For payers, the practice is just reaching their radar screens.
HIM professionals should be on the look out for these EHR documentation bad habits, as the consequences could harm both patients and facilities. The Dangers of Copy and Paste Documentation shortcuts are tempting for busy clinicians.
The innovation of the EHR, which allows for easier movement of information, has made it easier to reuse previous documentation with a single click.
But the practice can lead to serious consequences for both patient care and reimbursement, some auditors say.
Trites has witnessed poor practices firsthand while working as an auditor. The most common is copying information from a previous encounter and pasting it as current documentation. The practice goes by several names—copy and paste, cloning, carrying forward—but it has the same effect on the integrity of the medical record, Trites says.
Copying information can go farther, as noted in a paper in the April issue of the New England Journal of Medicine. This is, in essence, a form of clinical plagiarism with potentially deleterious consequences for the patient.
It can make tracking disease outbreaks harder, Gelzer says. Such documentation may also show physicians performing services they only performed once in the past, leading to over reimbursement. Documentation should be recorded for each specific encounter, Trites says.
Anything beyond that could be considered fraud. And so the auditor begins to wonder, how is the facility coding these records? How does it make sure it is submitting accurate claims?
In some instances scribing, or authenticating notes made by another person, can be a fraudulent act if not acknowledged. Scribing has long been a practice on paper charts, but it can be harder to recognize in some EHR systems.
For example, a medical assistant may complete a history and physical on a patient in totality. The supervising physician may subsequently log in to the record, evaluate only proof of positives and negatives, and electronically sign the documentation in such a way that it overwrites the presence of the medical assistant.
That overwriting misrepresents who provided the service, which could alter the amount that is billed, Gelzer says. For example, she says, some EHR programs offer physicians the ability to mark a single checkbox indicating that all patient systems are either normal or abnormal.
The problem occurs when the doctor mistakenly checks the wrong box, leading to improper documentation. When Drury advises physicians on which EHR products to purchase, she at times advises against products that feature copy-and-paste functions.
This can cause an uproar. Stephen Levinson, MD, consults with physicians on quality and compliance issues related to electronic documentation. He warns against the confluence of time-crunched physicians and the lure of documentation shortcuts.
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