Wiki Coping and Pasting previous records.

[TLGray]

I am coding for Oncology and my physicians are coping and pasting notes from previous records and putting them under History of Presence of Cancer at the beginning of the chart. When they take it from more than one previous record they do include month and year of the each record. Can I count this as review and summarization of old records? Any advise would be greatly appreciated.

 

[wynonna]

History of Present Illness can only be gathered and documented by an MD, PA, or APRN

 

[TTcpc]

I am coding for Oncology and my physicians are coping and pasting notes from previous records and putting them under History of Presence of Cancer at the beginning of the chart. When they take it from more than one previous record they do include month and year of the each record. Can I count this as review and summarization of old records? Any advise would be greatly appreciated.

Hello,

I suggest asking your providers about their reasoning behind the copy/paste if you have that ability/relationship. I often find physicians to be less confrontational when you ask them questions rather than going after them all of the time. Our hem/onc providers did and when we sat down as a group and discussed it, their reasoning for doing this was to have all of the more recent treatment/response information convenient for them. If it is from their own notes, then no you would not count it towards summarization of old records. If it's from someone else's notes, I wouldn't count it if it had already been copied/pasted into a previous note. Sometimes you have to remind them that for subsequent visits what counts is what has happened in the interim.

I hope this helps