Gastroenterology Coding Alert

Question: One of our interns sometimes helps out as a scribe. I have noticed that he sometimes adds notes pertaining to the exam, assessment, and treatment to the record of an encounter before it even begins. This doesn’t seem OK, but I want to be sure before I say something. Can you confirm?

Louisiana Subscriber

Answer: This situation is loaded with compliance red flags. How can anyone anticipate what will happen in an encounter before it happens? Although cloning notes often feels like saving time, it is unethical and can cause a lot of headaches down the road. Remember, a patient’s record, including documentation of their visits with their healthcare providers, is the narrative that informs their current and future care. Cloning or copying and pasting or otherwise not recording information accurately and honestly can skew treatment a patient receives later in life. While a practitioner can dictate what happens during an encounter or use a scribe, the situation you’re describing is not compliant with ethical documentation.