Hi does anyone know where I can get some guidelines or information on cloning of the body of the OP note? I have a provider copying surgeries from other notes (that are the same kind of surgery) and just changing the level of the spine that is being operated on. I need to provide him with some kind of guideline or clear information that clearly states this is not allowed. Thank you!!
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Wiki Op note cloning
- Thread starter thbond
- Start date
SharonCollachi
Guest
Why do you think this is not allowed? If he did exactly the same thing, why do you think he should create it from scratch every time? Now if he is not adding in complications or other difficulties, that would be a problem.
Orthocoderpgu
True Blue
Sharon is correct on both points. Templates are allowed but complications and other specifics should be included to make sure that the op note documented is specific to the patient. The problem that I see is that surgeons who use templates never actually do this and so all of their op reports read exactly the same which is a compliance issue. Can they use templates? Yes, but should they? If they are not going to individualize it, no. It becomes a compliance issue.
thomas7331
Guest
Yes, I agree with what the others have said here. I actually had a provider tell me once that it would be considered malpractice if they did NOT do exactly the same procedure for every patient because medical standards require that they perform their procedures in accordance with the required steps. They would only deviate from procedure if a unique and particular patient anatomy or illness dictates that something different be done in that particular case, which of course would need to be documented.
The one thing though I do see sometimes that is very problematic is when a provider will use as template that says something like "if the patient had x, then y was done". Language such as this has been specifically prohibited because it does not document what actually took place at the encounter and is certainly something that should be brought to a provider's attention.
The one thing though I do see sometimes that is very problematic is when a provider will use as template that says something like "if the patient had x, then y was done". Language such as this has been specifically prohibited because it does not document what actually took place at the encounter and is certainly something that should be brought to a provider's attention.
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Thank you everyone for your responses. I do agree that they shouldn't have to start over from scratch for each OP note, though what I am encountering with this provider is the almost the whole OP note is being copied from other patients notes, he is not using templates. My boss and I feel this is comprising patient safety issues and documentation errors. If he was using templates it wouldn't really be an issue, but he is copying from other patients' notes. Besides the regular CMS guidelines on cloning, do you know of anything specific to OP notes?