Updated August 2012
The advent of Electronic Health Records (EHR) brings an unexpected consequence. Medical record documentation is being duplicated from one visit to the next, through cloning, copy forward, or cut and paste of previously documented patient information.
This creates a significant compliance issue if the information cloned is determined to negatively impact the quality care of the patient.
Where is the substantiation that this care was provided again?
Was the cloned information actually representative of the current visit?
If there is a discrepancy, does that possibly lead to potentially improper payments?
AISHealth re-printed a report from Report on Medicare Compliance that addresses some of the significant issues related to the cloning of medical records. The article discusses some of the formidable challenges that some hospitals and their compliance officers will have to face, as well as the pros and cons of using templates.
Physicians’ offices should also be aware that while Medicare is identified and discussed in this article, private payers have already experienced electronic documentation challenges.
Prevent compliance issues by taking the following steps:
Review your EHR documentation and assess your documentation style
Check that your documentation adheres to the Medicare Contractor Policies provided in the article
Be proactive and include a review of your use of carry forward documentation within your compliance plan.
Read the AISHealth article for more information.