# Cut & Paste? Help!



## btadlock1 (Jan 6, 2011)

I'm reviewing a lot of charts for one provider, and I've noticed that regardless of what else is documented on the exam, these things are ALWAYS documented - the same way, every time...

Gen. AOx3
CV: RRR S1, S2
Respiratory: CTA
Abdomen: Active x4, Soft, non-tender
Extremeties, no edema.

Is this okay? Some of the notes are handwritten, and it looks like the information is filled in out of habit - it's always positioned the same way on the note, in about the same spot. I can't even be sure that the doctor actually checked it. Would this be considered cut-and-paste documentation? And if so, how is it any different than using a template instead? I've really got to get an accurate audit on this clinic, and I don't want to give them credit for something that the OIG wouldn't. This info makes the difference between having enough for a separate E/M, or not. Any help would be much appreciated!


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## FTessaBartels (Jan 7, 2011)

*Mental checklist*

Physicians who have been examining patients for a while and documenting those visits tend to have their own internal checklist for their findings.  They will use the same phrases over and over, especially when there is no "abnormal" finding.  And they will document the exam in the same order (vitals, Eyes, ENT, resp, CV, GI, GU, MS (extremities), skin, neuro, psych).

That's not cut-and-paste, nor is it in any way indicative of their not having performed what they document they have performed. It is perfectly fine. 

I used to transcribe for physicians with patients in the ICU. Very sick patients. And I recognized patterns in the way each physician recorded certain information.  Doesn't mean they didn't perform the exam, it was just the way they phrased their documentation. Today, if I read just the exam portion of a note from the ICU, I could probably still identify which doctor was seeing the patient, just by recognizing certain phrasing. 

Hope that helps.

F Tessa Bartels, CPC, CEMC


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## preserene (Jan 7, 2011)

FTB is absolutely correct and well said. that is the way their fast track  happens to be.
Each and every doctor often identified "at non-face to face scenario' with their phrasing as FTB said and most often are unique for that individual, though this has been represented many times and in many ways; this could not be helped though the doctors are very much aware of such things. this is not takenoften as issues with their coworkers staff. As days pass on, the staffs read them very easily and delightfully.
But yet there are many universally accepted medical abbreviations and all doctors invariably adhere to them.
Some of the examples are those as Btadlock mentioned. here they are:

RRR – regular rate & rhythm  
CTA Clear To Auscultation .  CTAP- Clear To Auscultation and Percussion.

A&O x 3 alert and oriented to person, place, and time. A&O x 4 alert and orient to person, place
Abdomen Active x 4- Abdomen active in  Quadrants.

Hope i made some sense.
Thank you for your time.


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## btadlock1 (Jan 7, 2011)

*Fraud-ish?*

Yeah, I guess you'd just have to see it to understand why I thought it looked funny - it's just the way that it was arranged on the page. I made them a template, though, so it would save them time and it wouldn't look so redundant. 

Let me get an opinion on this hypothetical situation...
Dr. A is employed by Group X, as the medical director for a specialty clinic. His wife, Dr. B, is not. Dr. B needs to perform a required number of specialty exams before she can obtain the same certification as Dr. A, so they decide that she could just perform the evaluations at Group X's clinic (without the Group's knowledge). 

For the specialty clinic to remain accredited, Dr. A must perform a minimum percentage of the evaluations; so, for both Dr. A and Dr. B to satisfy their required duties, they both examine the same patients, presumably at the same time. On some records, they make separate entries into the chart; but on a few, there is just one note, with both doctors' signatures on it. Would that render the note useless for billing and/or accreditation purposes? And if so, is there any remedy?

And a related question, should some kind of action be taken against Dr. B for recording some of her evaluations on home-made Group X letterhead (as though she's legitimately associated with the Group)? It all just seems fishy (hypothetically, speaking...)


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## mitchellde (Jan 7, 2011)

I am wondering about a possible HIPPA violation with Dr. B seeing patient's without the knowledge of the Group X physicians other than the husband.  She has access to patients medical and personal information without having permission so to speak to be involved in the the patient's medical care.  Would this not be close to the same as, A Hosptial CEO accessing a high profile patient's record just to see the information?  HIPPA says that as long as it is part of your required and normal job function to have access to the chart then it is OK.  A physician that has not been consulted and is not employed with the Group has no official need to have access to the patient record.  
This is just a thought.  I just think this whole arrangement is not right and could be placing the entire practice at risk.


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## btadlock1 (Jan 7, 2011)

I agree; however Dr. B's access to the patients' records is only speculative. All that can be proven at the moment is that she evaluated some of the patients, within her scope of practice. There's no indication that she ever accessed prior records. 
Group X is working to correct the situation immediately. Or so I hear...


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## mitchellde (Jan 8, 2011)

It just seems so strange!


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## jimbo1231 (Jan 9, 2011)

*Cut and Paste*

Brandi,

I don't see a problem with the order being the same. I agree with docs getting into habits. But if the findings are all always the same, I'd be a bit concerned. Then it starts to look to me that they write the same thing no matter what. I mean some people do show up with swelling of extremties from time to time. And I do think sooner or later the government will get around to noticing all these Detailed and Comprehensive records that look alike.
But if it's just a matter of how they order the record, it's OK.

Jim Strafford  CEDC   MCS-P


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## btadlock1 (Jan 9, 2011)

jimbo1231 said:


> Brandi,
> 
> I don't see a problem with the order being the same. I agree with docs getting into habits. But if the findings are all always the same, I'd be a bit concerned. Then it starts to look to me that they write the same thing no matter what. I mean some people do show up with swelling of extremties from time to time. And I do think sooner or later the government will get around to noticing all these Detailed and Comprehensive records that look alike.
> But if it's just a matter of how they order the record, it's OK.
> ...



That is why I was concerned - there were some notes that gave the impression that it was already written before the rest of the exam was filled in. I really think the template will help to avoid that in the future though - she was essentially hand-writing a template for herself with every patient, and it just made everything look a little too uniform. I know that I'm not really conveying what was weird about it, so I'll try to show what I meant...Imagine this is hand written, and oriented on the page the same way as I type it...

"Objective:
Mallampati score: 2..........Neck circumference: 18"
Nocturia: 2-3X per night

........Gen: AO X3..........................CV: RRR S1, S2
...........Resp: CTA, RA............................Abdomen: Active X4, soft, non-tender
............Extremities (-) edema

Assessment:..."

Now imagine the red portion being nearly identical to that - positioning included - on every chart. It just looked really funny.


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## btadlock1 (Jan 9, 2011)

*Agh!*

That last post didn't show up like I wanted it to - I may have to edit it to make it space correctly...


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