Wiki EHR cloning

[JJENNETT]

The Dr. does an office visit on 09/01 and admitts the same patient on 09/10.
The notes are identical except for 2 items in the plan and impression for 09/10
My take on this is that the cloned note on 09/10 cannot be used because that exact information was already used on 09/01.
may I get some feed back on this ?
thank you

 

[MarcusM]

The Dr. does an office visit on 09/01 and admitts the same patient on 09/10.
The notes are identical except for 2 items in the plan and impression for 09/10
My take on this is that the cloned note on 09/10 cannot be used because that exact information was already used on 09/01.
may I get some feed back on this ?
thank you

This is the crux of the problem. EHR is supposed to make a provider's job easier for documentation. However, when the HPI/physical exam/notes/ROS/etc is the same as a prior visit, then auditors/payers/coders have an issue because the provider "clones" or copies or templates the prior information which then creates a visit that "looks" like the provider did not do a thorough evaluation, when in fact he most likely did. So now the auditors/payers don't want to pay the provider. Does the provider now change the wording on each encounter just so he is not accused of cloning? This defeats the specific intent and purpose of EHR.

 

[Lyta2000]

Actually I review medical records for a living and I disagree. I have personal experience with cloning. It is detrimental to the record and I am glad cms is cracking down on it.

 

[jdibble]

This is the crux of the problem. EHR is supposed to make a provider's job easier for documentation. However, when the HPI/physical exam/notes/ROS/etc is the same as a prior visit, then auditors/payers/coders have an issue because the provider "clones" or copies or templates the prior information which then creates a visit that "looks" like the provider did not do a thorough evaluation, when in fact he most likely did. So now the auditors/payers don't want to pay the provider. Does the provider now change the wording on each encounter just so he is not accused of cloning? This defeats the specific intent and purpose of EHR.

I have a similar issue with my providers. The EHR allows them to "clone" the HPI, ROS, PFSH and Exam from the previous visits. The carried forward documentation is not appropriate for the current visit - i.e. "Pt here for chest pain for the past 2 weeks" on the first visit, then on the 2 month f/u visit it states "Pt here for chest pain for the past 2 weeks" with a statement of "no sob or chest pain" added. How is this appropriate? Yes the provider needs to change the wording on each encounter to reflect what has been happening between the last encounter and this encounter. I really do not think that the intent or purpose of the EHR was to plagerize from a previous visit. This is not appropriate for good patient care and should not be allowed! Also, just because the doctor has cut and pasted an exam from the last visit, does not mean that he did that same exact exam with the same exact results! Again, my doctors bring forward the last exam from the previous visit no matter what the patient is here for...they are here 2 weeks after their initial visit to go over test results. This does not warrant a detailed exam, however they cloned the previous exam and this makes it appear that they did more work than I am sure they must have done - or needed to do based on medical necessity. I am working on getting this issue stopped in my practices and I think that it is good that CMS is cracking down on it. The EHR companies really need to rethink how their programs work and create a product that can be used correctly and in compliance with CMS guidelines!