Question When is a pre-built Template taking it too far?

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5
Location
Citrus Heights, CA
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I have a provider that has a pre-formatted template that looks like the entire note is complete with already generated diagnoses and labs/procedures. Absolutely nothing prompts entry by the provider and it's a complete note with HPI, ROS, Exam and A/P. This is a data integrity issue but I'm not able to find clear resources to specify what is allowed regarding prompts and templates. Would anyone be able to provide additional resources or reference on this matter?
 

Mayzoo

Expert
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272
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Tyler, TX
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These are not precisely what you asked, but I think they are fairly close. Hope they help.

"Cloning—This practice involves copying and pasting previously recorded information from a prior note into a new note, and it is a problem in health care institutions that is not broadly addressed.[16, 17] For example, features like auto-fill and auto-prompts can facilitate and improve provider documentation, but they can also be misused. The medical record must contain documentation showing the differences and the needs of the patient for each visit or encounter. Simply changing the date on the EHR without reflecting what occurred during the actual visit is not acceptable. Using electronic signatures or a personal identification number may help deter some of the possible fraud, waste, and abuse that can occur with increased use of EHRs.[18] In its 2013 work plan, the U.S. Department of Health and Human Services, Office of Inspector General (HHS-OIG) indicated that due to the growing problem of cloning, its staff would be paying close attention to EHR cloning.[19, 20] "


This source (not cms) questions the safety of copy and paste: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5373750/

"Copy-Pasting. Copy-pasting, also known as cloning, enables users to select information from one source and replicate it in another location.7 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 "


"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. "

 
Messages
5
Location
Citrus Heights, CA
Best answers
0
These are not precisely what you asked, but I think they are fairly close. Hope they help.

"Cloning—This practice involves copying and pasting previously recorded information from a prior note into a new note, and it is a problem in health care institutions that is not broadly addressed.[16, 17] For example, features like auto-fill and auto-prompts can facilitate and improve provider documentation, but they can also be misused. The medical record must contain documentation showing the differences and the needs of the patient for each visit or encounter. Simply changing the date on the EHR without reflecting what occurred during the actual visit is not acceptable. Using electronic signatures or a personal identification number may help deter some of the possible fraud, waste, and abuse that can occur with increased use of EHRs.[18] In its 2013 work plan, the U.S. Department of Health and Human Services, Office of Inspector General (HHS-OIG) indicated that due to the growing problem of cloning, its staff would be paying close attention to EHR cloning.[19, 20] "


This source (not cms) questions the safety of copy and paste: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5373750/

"Copy-Pasting. Copy-pasting, also known as cloning, enables users to select information from one source and replicate it in another location.7 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 "


"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. "

Thank you! This was very helpful.
 
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