Wiki Electronic Healthe Record - Cut and Paste

[Inquisitor]

When a provider is obviously cutting and pasting from prior encounters to the current encounter, do you count only the new information? What if the provider says they performed the same tasks at the current encounter? Education is obviously in order, but what would you count toward the current E/M?

Thanks...

 

[ARCPC9491]

When a provider is obviously cutting and pasting from prior encounters to the current encounter, do you count only the new information? What if the provider says they performed the same tasks at the current encounter? Education is obviously in order, but what would you count toward the current E/M?

Thanks...

When you say cut and paste..are you referring to the history? Anything in the CURRENT note applies to the level of E/M...you can copy and paste what you'd like HOWEVER this leaves a lot of room for error and I don't always recommend it. The providers need to be careful they aren't routinely doing this and forget to change it if something pertinent pops up! To better understand...be more specific when you say 'they performed the same tasks'....

 

[Inquisitor]

Referring to an entire note being cut and pasted to a current encounter with a few changes made in each of the 3 key components.

 

[ARCPC9491]

You can do that - there's nothing that says that you can't. But like I said, you're at a higher risk for confusion and medical error. I, personally, wouldn't recommend it. I feel as if it degrades the quality of the medical record.

 

[Inquisitor]

Electronic Health Record

I agree. Definitely education is in order here!