# Physical Exam Documentation



## PennyG (Feb 13, 2017)

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.


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## cdeak01 (Feb 13, 2017)

Check out this CMS link. 

https://www.cms.gov/Medicare-Medica...ownloads/docmatters-ehr-providerfactsheet.pdf


Cloning was also on the OIG work plan in past years


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## snjberry (Feb 23, 2017)

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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