One of the items that the Office of Inspector General (OIG) is looking into is multiple office notes that seem to be “cloned” or “identical.” There are many pitfalls that you can fall into using the “copy and paste” option on your electronic health record (EHR). Medicare contractors have noted an increased frequency of medical records with identical documentation across services. By copying and pasting documentation from previous notes, physicians can document more complexity in a visit than necessary by misunderstanding what happens when they use check boxes or use features such as “automated negatives.” You might even be surprised to see your own health assessment copy and pasted on another physicians note. With all these new tricks, a click of a button can generate a complete review of symptoms even though these were never reviewed by you with the patient. Physicians may be using templates with their EHRs so you need to be diligent when copying and pasting past notes, you do not want your documentation to read the same way for each visit. While this feature is helpful, it could become a problem during an audit if it’s not properly checked during each visit.
Do EHRs make it easier for you to code a higher level of service? Since the volume of documentation doesn’t always determine the code you should be using, make sure the medical necessity warrants the appropriate code you have chosen for each visit.
Here are some of coder’s favorite lessons that still apply for EHRs:
- “If it’s not documented it wasn’t done”
- The EHR must still follow the same guidelines for documenting as when you documented in paper charts
- Just because the information is found somewhere in the EHR, it will not be counted towards your documentation unless you note the date of service as a reference in your documentation
- The saying “your note has to stand alone” still applies with EHR documentation
- Make sure that your review of systems is pertinent to the patient’s chief complaint
- Ensure that all EHR documentation authorship is accurately recorded
- Check that the automated code generated is associated with your documentation and correct based on your medical decision making
- Beware of automated change of “Note Author”
- Beware of fields that have automatically populated answers