Wiki Cloning and templates

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jdibble

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I have just started working for a hospital based physician practice that is using eClinical Works. I have been working on auditing the cardiologist practice at this point and have been seeing that for the patient's HPI for follow-up visits, they bring the old HPI forward, which makes no sense when you read the note - i.e. cc is 6 month f/u and HPI starts with - Patient here for chest pains for the past few weeks, etc. then the last sentence says no chest pain, or chest pain better. These leaves the note with really no HPI for the current visit. Then the ROS and Exam are templated - and each visit is exactly the same, whether it is their first visit, 2nd, 3rd, etc. Every now and then there is a short note of a change, but mostly every patient visit is documented the same.

Is this appropriate documentation for an EHR? I have never really audited for an EHR before and just wondering if anyone had any guidelines or information on what is considered appropriate use of a template and if this scenario is considered the normal use?

I am just not seeing how this can be considered correct documentation! :(

Thanks, :confused:
 
There is transmittal from CMS last year regarding the use of templates and cloning. You should go to the CMS website and search thru the transmittals. But no you are not to cut and pate info from a previous encounter. And limited choice templates that are just a check mark style are highly frowned upon and CMS discourages the use of these.
 
Dawn

Jurisdiction 11 Part B Palmeto GBA/CMS
Medical Record Cloning
The word 'cloning' refers to documentation that is worded exactly like previous entries. This may also be referred to as 'cut and paste' or 'carried forward.' Cloned documentation may be handwritten, but generally occurs when using a preprinted template or an Electronic Health Record (EHR). While these methods of documenting are acceptable, it would not be expected the same patient had the same exact problem, symptoms, and required the exact same treatment or the same patient had the same problem/situation on every encounter.

Cloned documentation does not meet medical necessity requirements for coverage of services. Identification of this type of documentation will lead to denial of services for lack of medical necessity and recoupment of all overpayments made.

With e-CW in the patient's note under the details icon at the bottom of the page, you can click chart access and that will tell you who entered what on that date of service. If it does not show that your provider entered or modified the HPI, I would discount the HPI on an audit. Hope this helps!:)
 
dawnebrennan said:
With e-CW in the patient's note under the details icon at the bottom of the page, you can click chart access and that will tell you who entered what on that date of service. If it does not show that your provider entered or modified the HPI, I would discount the HPI on an audit. Hope this helps!:)
Click to expand...

Thanks everyone for your answers. I have checked out that information and it has been helpful. I have found alot of info out there about cloning and how it is not acceptable. I just haven't found much out there about the use of templates and what is considered the correct usage. This template is prepopulated with the responses already entered as such:

Cardiovascular Examination
General Appearance: alert and oriented.
HEENT: normocephalic/atraumatic, no thyromegaly, no adenopathy.
Carotid Upstroke: Normal.
Jugular Venous Distention (JVD): Normal.
Chest: Normal.
Lungs: clear to auscultation bilaterally.
Heart: regular rate and rhythm, normal S1, S2, no murmur, rub, gallop or click, PMI normal.
Abdomen: soft, non-tender, non-distended, no organomegaly, bowel sounds present throughout.
Extremities: warm, no edema, no clubbing or cyanosis.
Peripheral Pulses: 2+ bilateral DPs.
Neurologic: alert and oriented x 3, no motor, sensory deficit.

This is the same exam documented on every patient, every visit, and the only change I have seen is the occassional change to patient has edema. This is used on all new patient's and even patient's coming in for a follow-up. I don't know if this is considered appropriate documentation!

Dawn - thanks for the info on eCW. I have tried to look where you indicated but that just comes up a blank page. I will keep looking though because that was another issue I am having - who is entering what documentation - doctor or CMA on behalf of the doctor!! If only someone here would have trained me on this system maybe I could find my own answers! :rolleyes:

Thanks again for all the responses!
 
This is a typical cardiac system exam. The pattern would be the same, but the problem is when all the answers are the same. New or established patients have a similar single system exam, but the HPI, PFSH, ROS and decision making would need to be different from patient to patient. I agree with you, when the note contradicts itself and all patients are just fine, it's time to educate providers.
C. Collison CPPM
 
ccollison said:
This is a typical cardiac system exam. The pattern would be the same, but the problem is when all the answers are the same. New or established patients have a similar single system exam, but the HPI, PFSH, ROS and decision making would need to be different from patient to patient. I agree with you, when the note contradicts itself and all patients are just fine, it's time to educate providers.
C. Collison CPPM
Click to expand...

Thanks! That is helpful information! They do use this same exam for each patient, for every visit, whether they are new, establised - here for a 6 month follow-up, or a 2 week follow-up for review of stress test results! They also use the same template for the ROS (a complete ROS)for each patient for every visit!

We will be looking into having the vendor provide other templates so that the physician can use one appropriate for the visit type!
 
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