As more and more practitioners embrace electronic medical records, the U.S. Department of Health and Human Services Office of Inspector General has made it known that they will begin to scrutinize how these records are completed. Healthcare fraud can be as easy as hitting Control-C, control-V although your intentions may just be to improve documentation efficiency. Federal officials say the cut-and-paste features common to electronic medical records invite fraudulent use of duplicated clinical notes and that there is a need to clamp down on this emerging threat. High priority in audits is the use of “cloning” (inappropriate use of the copy-paste feature) and over-documentation as therapists seek “short cuts” in using EMR. The OIG has recommended that the Centers for Medicare and Medicaid Services evaluate electronic medical records for fraud vulnerabilities. If fraud is suspected, practices will be subject to fines and penalties. The copy/paste functionality in EMRs can result in redundant, and erroneous health record documentation.
Here are some tips:
Make sure you avoid repeating past information and review all entries in your note.
CMS guidelines state that a review of a past medical, family, and social history obtained during an earlier encounter does not need to be re-recorded if there is evidence that the therapist reviewed and updated the previous information. Simply put, in your note, you can refer to a previous note that has a comprehensive history of the patient. You can write, “See note dated 8/1/2014 for a comprehensive history of patient A,” and then update the present concerns/reason for the visit.
Confirm that all the diagnoses listed are relevant for that particular visit.
EMR systems often offer the option of copying of all diagnoses listed in the problem list. That may include those diagnosis that have been resolved or are not relevant to that day’s patient visit. List only the diagnoses that are relevant for the reason the patient is seeing you – do not just cut and paste the whole list.
Your note should be individualized for that patient’s encounter.
EMR systems often allow you to cut and paste (clone) an entire previous note. Auditors always look for patterns in documentation, so take great care in using this feature. You will be cited for not providing individualized care if all your notes over time are substantially the same for an individual patient as well as other patients you treat. Make sure each note is relevant for that day’s visit.
Make sure you include a policy on the use of cloning, the copy-paste feature in your policy and procedure manual. Step one to making sure this is not happening in your practice is having a policy and procedure in place. Auditors will look to see if you do, and many practices have not updated their policies when they shifted to EMR. A policy should detail how your practice will safeguard against the misuse of the copy and paste functionality.
Date: August 13, 2014