Wiki Copy/pasting notes for reference

[bridgettemartin]

I need input from auditors and/or compliance.

A provider sees a patient in the Urgent Care setting. He copies a portion of the patient's PCP's last office visit and pastes it into his note with a statement about it being pasted for reference only. His note otherwise has all the components of an E/M service.

I can't find any regulations that prohibit this, but I am concerned about the pasted portion of another Provider's service, now being a part of this Provider's service, especially if this note is sent anywhere else. Not sure if this would be considered Redisclosure. Can anyone direct me to resources that discuss this?

 

[em2177]

CMS has quiet a bit of information on this.

1. Information that is copied, pasted, imported must be attributed to the original source.

2. The purpose of a progress note is to provide an accurate depiction of treatment on a specific date of service. It is unnecessary to duplicate by copying and pasting information that does not specifically impact a specific date of service.

3. Occasionally a lab result may be helpful in clarifying treatment and it is appropriate, on a selective basis, to include those results in the note by referring/repeating them without copying and pasting verbatim into the note. It is inappropriate to fill the progress note with redundant information (information already available in a section of RPMS), such as lab results, radiology reports, or other ancillary information that is pulled in by a template or copied and pasted. Such redundant information makes it difficult to read the progress note and quickly elicit pertinent facts about a specific date of service. A liability issue may occur when abnormal lab results, x-rays, etc., are contained within the body of a note but not addressed in that note.

 

[tylene1993]

Copy and pasting

We have a provider who is copying and pasting his entire note from the previous visit and only changing a word here and there. Sometimes he will put in a new plan but the History of Present Illness and Physical Exam are copied word for word from the prior visit. Are there any guidelines out there that prohibit this? I know that it is not good patient care and can inflate the billing levels. We are trying to get him to stop doing this but are needing some really good guidelines (or links) on this to back us up. If you could give me some guidance on this that would be great and the sooner the better.


Tylene Garner, RHIT, CPC

 

[thomas7331]

The use of copy/paste in electronic health records is not prohibited and is acceptable if used appropriately. CMS and OIG frequently warn providers of the potential problems with EHR systems and recommend caution and monitoring to prevent compliance issues. Here's a good brief article - you can refer to the section on 'cloning' on page 2 and the other articles referenced at the end:

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

There are also publications available on line from the OIG that address this in a similar way. You won't find anything saying that copy/paste is not allowed, but it goes without saying that inaccurate information in the medical record is unacceptable. CMS and OIG recommend 'integrity practices' to ensure quality in the medical records and accurate billing. Practices should routinely audit for this and if findings show that providers misuse the copy/paste, I know of organizations that have actually disabled the function in their systems to prevent providers from using it, so that might be an option you can pursue if you can't get your provider to use it appropriately. At the same time, I'd recommend not overreacting - providers do have standard practices that they follow, such as a routine exams or procedures that they do for each patient for a particular type of problem, and it's normal to see identical templates used for these things. The more important thing is that the record be accurate and that it reflect the particulars of each individual patient. Work together with your practice management and/or compliance officer on this as it really helps to have the participation of someone who can weight the risks and who has real leverage over the provider to get change if needed.