Wiki EMR - Copy & Paste

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ARCPC9491

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I have a practice who for every patient, no matter what their presenting problem is, is copying and pasting the entire comprehensive history "because it helps them get a higher level visit" (quoted by the office manager)

The history should be a direct reflection of the nature of presenting illness. Copying and pasting does allow for higher levels but if it isn't pertinent or necessary to do, I don't feel as if they should really be given credit.

If the patient comes in with a broken finger, it doesn't make sense to do a full review of systems.

Comments and suggestions??
 
Are they copying from the patient's previous encounter, or a standard template for everyone?

I would think if they use the patient's personal history as a template and then note that there were no changes or something, that would be ok. The exam, MDM and medical necessity would bring it back down to where it should be.

If they are copying and pasting a standard form that is the same for everyone, then you have issues.

I thought there was something about that on the Medicare website, but am unable to locate it at the moment. I'll let you know if I find it. Maybe someone else knows where it is?
 
There is really so much more at stake here when records are copied and pasted, or moved forward, in EMR/EHR. Copy and paste may be a good function for test results and old medical records that are added, but the history component may be best left out of this practice.

In this day and age, cloning documentation, or copying and pasting can get a provider and staff into a lot of trouble. Including you, if you allow it to continue. Now, I don't want to scare you, yet this is truly a serious concern.

Documentation guidelines indicate that "relevant history" is expected to be documented. That means relevant to that visit's HPI.

EMR/EHR companies do have an ability to turn off the component that allows a patient's history to "travel" from one visit to another. IMHO, I recommend turning the travel button off and leaving it off.

WPS Medicare Part B has some information in regards to history documentation that indicates it needs to be "relevant history'. These may be found at:

http://www.cms.hhs.gov/MLNProducts/downloads/eval_mgmt_serv_guide.pdf

http://www.wpsmedicare.com/part_b/education/evalmngmntqahistory.shtml

Also, the following sites contain wonderful documentation guidance and information regarding cloned and/or copied and pasted documentation:

http://74.125.95.132/search?q=cache...d+and+pasted+history&cd=1&hl=en&ct=clnk&gl=us

http://www.aishealth.com/Compliance/ResearchTools/RMC_Compliance_Risks_EMRs.html

https://www.mmgma.com/programs/RIAssembly08/Pinnacle_prez_101408.pdf

http://www.eclinicalworks.com/2006-05-01-pr2.php

Lastly, the following site contains a 2008 indictment of a provider for mail fraud due to billing BCBS for services that were "upcoded' due to documentation concerns such as this:

http://www.usdoj.gov/usao/pae/News/Pr/2008/feb/kingind.pdf

I hope this helps at least give you some good ground to move forward from. Good luck!

Kris
 
Thanks Koyote

Your links were very helpful in my quest to educate one of our providers. I also found a really good article at the AHIMA web site under Guidelines for EMR.
 
EMR Copy & Past

I"m a Medical Auditor with the Controls & Compliance Department's Fraud Department. When EMR's are sent for audit that are "canned documentation" or "copied and pasted" to a patient's visit from one note to the other repeatedly it raises red flags. Whether it's the same patient's medical record or if the "canned documentation" has not been individualized to each patient's visit complaint or assessment... that will also raise red flags. Those red flags will expand the audit for more medical records at the very least.
I wouldn't recommend "copy and past" as a common practice of operation. Good Luck on your efforts with education!:)
 
This is interesting. My employer is very lenient with copy and paste and considers it legal.

As far as the initial question, I agree medical necessity would override. If the comprehensive history is not necessary for the condition, it would not help with a higher visit level.

Here are the links to the AHIMA articles if anyone is interested:

http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_038463.hcsp?dDocName=bok1_038463

http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_042416.hcsp?dDocName=bok1_042416
 
Coping and pasting with ehr

koyote said:
There is really so much more at stake here when records are copied and pasted, or moved forward, in EMR/EHR. Copy and paste may be a good function for test results and old medical records that are added, but the history component may be best left out of this practice.

In this day and age, cloning documentation, or copying and pasting can get a provider and staff into a lot of trouble. Including you, if you allow it to continue. Now, I don't want to scare you, yet this is truly a serious concern.

Documentation guidelines indicate that "relevant history" is expected to be documented. That means relevant to that visit's HPI.

EMR/EHR companies do have an ability to turn off the component that allows a patient's history to "travel" from one visit to another. IMHO, I recommend turning the travel button off and leaving it off.

WPS Medicare Part B has some information in regards to history documentation that indicates it needs to be "relevant history'. These may be found at:

http://www.cms.hhs.gov/MLNProducts/downloads/eval_mgmt_serv_guide.pdf

http://www.wpsmedicare.com/part_b/education/evalmngmntqahistory.shtml

Also, the following sites contain wonderful documentation guidance and information regarding cloned and/or copied and pasted documentation:

http://74.125.95.132/search?q=cache...d+and+pasted+history&cd=1&hl=en&ct=clnk&gl=us

http://www.aishealth.com/Compliance/ResearchTools/RMC_Compliance_Risks_EMRs.html

https://www.mmgma.com/programs/RIAssembly08/Pinnacle_prez_101408.pdf

http://www.eclinicalworks.com/2006-05-01-pr2.php

Lastly, the following site contains a 2008 indictment of a provider for mail fraud due to billing BCBS for services that were "upcoded' due to documentation concerns such as this:

http://www.usdoj.gov/usao/pae/News/Pr/2008/feb/kingind.pdf

I hope this helps at least give you some good ground to move forward from. Good luck!

Kris
Click to expand...

I am currently auditing a provider with copying and pasting issues. Thank you for these websites. Some of them I already had, however the AIS Compliance is a good article. Thank you for your help Peggy CPC
 
Coping and pasting with ehr

I currently auditing a practice who are cloning or copying and pasting the patient's medical record for each visit. I need to find out what everyone thinks about this particular issue I'm seeing. The note is copied forward with only one word change or just a couple but the rest of the note is exactly the same as the previous records. I'm still auditing the record as cloned, the limited amount of added information does not support the medical necessity of why the patient is there. I've talk to others at my organization and they state that if there is one word or a couple of words changed then it's not cloned. Is one word or a couple of words enough of a modification of the record? I've shown them the articles above and even some other ones that I found.
 
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