Wiki E/m auditing


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When an established patient comes in does the physician have to update their exam or can they just carry it forward from a previous visit?

If they change/add one thing to the exam (one section not the whole exam) does this allow them to use the complete exam from the previous visit?

On the HPI I know they have to update it every visit and cannot copy and paste it from a previous visit but if a physician does I assume we cannot count the HPI when auditing the chart?

Any help or links for written information would be wonderful as I need to be able to explain to the physician why it cannot be copied and pasted with no changes made.

Thank you so much for any input
A good place to start is with some of the CMS and OIG publications that address the use of copy and paste. I've added links to a couple of documents below.

From the OIG report: "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 claims and duplicate or create fraudulent claims." It should go without saying that a provider cannot 'carry forward' an exam. The provider's signature on the medical record is a legal attestation of the work they performed at that encounter and their certification of the accuracy of the information. There is nothing wrong with using a template, but to copy and paste without customizing the information to the particular patient and visit is a very risky practice.

With respect to auditing, I always caution providers that if it becomes obvious to an auditor that copy/paste is being used too frequently or carelessly, it decreases the auditor's confidence in the accuracy of the notes they are reviewing and that's not a situation you want as it can lead to an expansion of the audit and closer scrutiny of all of the provider's records in the future.