Health Information Compliance Alert

For best results, follow CMS’ best practices.

When they complain about EHRs, clinicians almost always point out that the systems demand redundant information. Time-crunched physicians and clinical staff may be tempted to “copy and paste.” They do so at your health care organization’s peril, compliance experts warn.

“The cut-and-paste function allows providers to enter relevant information into a patient’s medical record more efficiently, which saves time on typing and leaves more time for patient care,” explains attorney Michaela D. Poizner of Baker, Donelson, Bearman, Caldwell & Berkowitz in Nashville, TN.

“But providers have to be careful that they don’t accidentally copy inaccurate information into a patient’s record,” Poinzer tells Health Information Compliance Alert. Misuse of the copy paste function can lead to erroneous health records, redundancy, upcoding, and even false claims.

Example: The progress notes from a previous visit are copied and pasted into the current visit record. The procedures were similar, so the physician feels the copying is warranted. However, if done haphazardly, the physician could copy previous services from the past visit that aren’t performed in the current visit. In this case,

the copy-paste action could create false documentation, which could lead to upcoding and to false claims.

“To practice responsible cutting and pasting, slow down,” Poinzer advises. “Double check that the copied text is going into the correct patient’s record, and read the text carefully to make sure that it’s accurate for the particular patient and doesn’t leave out important information.”

Steer Clear of Pre-Populated Templates

Prepopulating templates can also saddle your health care organization with clinical documentation troubles, experts warn.

It’s safer to use open-ended templates that force clinicians to choose answers in real time. For example, a good template allows clinicians to choose the symptoms rather than giving them a prepopulated symptoms list that is not unique to the patient at hand.

Cool Tool: The CMS ‘Decision Table’ for Copy-Paste

Earlier this year, CMS published a document to help you educate your clinicians about the compliance dangers of copy-paste. The Decision Table lists problematic copy-paste practices such as:

Copy forward: Copying large blocks of information or all information from a previous note to a current one.

Cut and Paste: Completely removing source text from original location to new location.

The CMS tool urges providers to establish policies that require staff to:

• Modify anything they copy so that it’s “patient-specific and related to the current visit.”
• Limit the use of the copy and paste function.
• Clearly note and attribute copied information.

As a further safeguard, the EHR system should “record the method of each data entry (for example, copy and paste or direct text entry),” the CMS document advises.

Editor’s Note: To access CMS’s Decision Table: Ensuring Proper Use of Electronic Health Record Features and Capabilities, go to https://www.cms.gov/Medicare-Medicaid-Coordination/Fraud-Prevention/Medicaid-Integrity-Education/Downloads/ehr-decision-table.pdf.