Wiki AUTO-POPULATE DATA ! Please help.

[1formissy]

Need some help here please! During my E/M audits, I noticed that the EMR the provider's use auto-populates a volume of diagnosis's that are not on the claim form, nor are addressed in the encounter. When I brought this up to the attention of the compliance committee, I was told that outside auditors did not document that was a problem, therefore it was disregarded.
I know that "exploded" information in the EMR happens all the time, and the point I am trying to get across to our IT department, is that data should not be auto-populated in the medical record each time a visit note is opened.
Does anyone know of a DIRECT link that clearly outlines this should NOT be done in the medical record? I have read through many articles on CMS, AHIMA, and I really need it to clearly say something to the affect that we should NOT be doing this.
Any help is really appreciated so I can get my point across and get this corrected with our practice. Thank you.

 

[kseebeck]

Just because the auditor did not indicate it was a problem doesn't mean it is not a problem. Maybe the auditor did not look specifically at the use of cloning.

I attached an AAPC article that I reference often regarding cloning.

Also included the CMS factsheet which states "features like auto-fill and auto-prompts can facilitate and improve provider documentation, but they can also be misused. The medical record must contain documentation showing the differences and the needs of the patient for each visit or encounter" and the OIG report which indicates that government oversight in coming with regards to EHRs copy-paste features (i.e. auto-populating information).

 

[Orthocoderpgu]

There is NO PLACE for auto population, copy & paste or anything similar in medical records. All they do is create inaccurate and confusing documentation that has no value. Not to mention the increased risk of being sued for malpractice because the documentation really does not capture what is happening with the patient. I'd rather go back to charts than have anything to do with auto population and copy & paste records, at least then you could see what was happening to the patient at every visit and how the patient was responding.

 

[1formissy]

Just because the auditor did not indicate it was a problem doesn't mean it is not a problem. Maybe the auditor did not look specifically at the use of cloning.

I attached an AAPC article that I reference often regarding cloning.

Also included the CMS factsheet which states "features like auto-fill and auto-prompts can facilitate and improve provider documentation, but they can also be misused. The medical record must contain documentation showing the differences and the needs of the patient for each visit or encounter" and the OIG report which indicates that government oversight in coming with regards to EHRs copy-paste features (i.e. auto-populating information).

Thank you. This is helpful. I am trying to help clean up the records so there is unnecessary and conflicting information.