Physical Exam Documentation

PennyG

Networker
Messages
80
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0
I have a physician who has copied and pasted the physical exam from the prior visit with no changes or additions. I am trying to tell this physician, this is not an acceptable practice, however, am not putting my hands on the appropriate documentation to show proof. I am hoping someone can assist me with getting the documentation to substantiate my thoughts.
 

snjberry

Networker
Messages
64
Location
Gouverneur, NY
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Copy-Pasting.
Copy-pasting, also known as cloning, enables users to select information from one source and replicate it in another location. 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.

https://oig.hhs.gov/oei/reports/oei-01-11-00571.pdf

Hope this helps
Sandi B CPC, CPMA
 
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