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Cloned documentation and modifications

  1. Default Cloned documentation and modifications
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    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.

  2. #2
    Charleston, WV
    According to AHIMA, “Documentation is considered cloned when each entry in the medical record for a beneficiary is worded exactly like or similar to the previous entries.” I believe CMS follows this philosophy as well.

    In order for cloned records to be accurate, the provider would have to read the chart line by line, and reevaluates it, to insure that it is up to date and truly reflects the patient's current status.

  3. Default
    Cloning EHRs (copy/cut/paste/pull forward): What began as a time-saving measure has mutated into a potential compliance nightmare. The point of cutting and pasting some or all of a patient's EHR medical record — known as cloning — into a subsequent visit was to promote efficiency, but it has wreaked havoc on accuracy, according to Rice and others. It's fine when only demographic and insurance information are cloned. But a Pandora's box is opened with cloning of clinical data. “You can have the wrong documentation or over-documentation or irrelevant documentation,” Rice says. “The clinical information may have no bearing on what has happened to the patient now and as a result, the patient presents as having more or less complex problems since the previous episode.”

    Suppose a patient previously had a heart attack and then subsequently comes in for hives. The physician takes the history and physical but forgets to amend the cloned version, so it seems like the patient had another heart attack. “People go on autopilot about cloning and information accumulates and accumulates and you can over-represent the case,” she says. Obviously, that would mean documenting and billing for a higher-level evaluation and management service than performed. Also, Rice notes, the use of cloning hinges on templates, another vehicle for abuse because they may invite the physician to check off diagnoses or conditions because they're there, even if they don't perfectly fit. For compliance purposes, Rice says, templates that are tantamount to orders must document medical necessity (e.g., time, date, diagnosis, reason per coverage policy).

    Vendors have not solved the cloning compliance problem for hospitals, Rice says. “There are no bells and whistles to clearly identify when a portion of text has been copied, pasted or cloned,” Rice says. “That could at least alert an auditor, who would be pointed in the direction if they are concerned.” Otherwise, auditing is like trying to find a needle in a haystack. The only option, therefore, is all or nothing; either you let physicians clone or turn it off. Rice has asked vendors about more refined EHR functions; her fellow compliance officers say they keep pushing for this. But EHR vendors tell Rice that “no one asks about this.”

    Another EHR documentation problem has cropped up. Some EHR systems don't record individual entries by individual authors, Rice says. They only note the last person in the specific section of the patient's chart. So, for example, if a resident treats a patient and then the supervising physician reviews the chart, the EHR system acts like the resident didn't exist. Rice was floored when she discovered this quirk. “That raises the compliance stakes higher,” Rice says. “Users of EHR need to ensure any system they choose will appropriately record the provider of care and/or author of the entry regardless of the timing of the entry. Systems that do not maintain the order and the authentication trail for individual entries run the risk of misrepresenting services and create liability for caregivers.”

    There's a meaningful-use aspect to this. One of the meaningful use criteria is to verify that electronic information has not been altered in transit. “This is huge for all the hospitals banking on meeting meaningful use and getting the money, especially if the government holds the strictest interpretation of the standard to mean any changes in entries,” and those hospitals have EHR systems that can't track changes made at the data field level, Rice says.

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