by NAMAS
Dec 13th, 2019
What did I do today?
Whether you are auditing inpatient or outpatient documentation, chances are you have come across a situation where the encounters repeat the same story, sometimes day to day, sometimes on every 3-month visit. When EHRs were implemented en masse, a key selling point of almost all of them was the ability to bring forward or copy previous documentation to help the provider be efficient in charting while allowing them more time with their patients. Over the years we have had major advancements to EHR technology, including the standardization of features such as "Hide Copied Text" and "Hover to Discover" which allows the auditor to see the information that was brought forward and even at times from exactly where in previous documentation it was copied from and who the original author was.
So how do you handle this as an auditor? Fortunately, CMS and many of our Medicare contractors have provided guidance on this subject. WPS guidance states, "Using templates, checklists, or the 'carry forward,' 'cut and paste,' and 'cloning' capabilities of your electronic health record system can be appropriate. The medical record, however, must be specific and complete for that patient for that date of service. The practitioner must document his/her review of information gathered by someone else or through the use of a template." (WPS Guides and Resources for E/M)
Official guidance by CMS defines cloning as follows: "This practice involves copying and pasting previously recorded information from a prior note into a new note, and it is a problem in health care institutions that is not broadly addressed. For example, features like auto-fill and auto-prompts can facilitate and improve provider documentation, but they can also be misused. The medical record must contain documentation showing the differences and the needs of the patient for each visit or encounter. Simply changing the date on the EHR without reflecting what occurred during the actual visit is not acceptable. Using electronic signatures or a personal identification number may help deter some of the possible fraud, waste, and abuse that can occur with increased use of EHRs. In its 2013 work plan, the U.S. Department of Health and Human Services, Office of Inspector General (HHS-OIG) indicated that due to the growing problem of cloning, its staff would be paying close attention to EHR cloning." (https://www.cms.gov/media/
In the inpatient setting it is not uncommon to see providers copy another provider's documentation and paste it into their own encounter. To do so without giving credit to the original provider, while adjusting the documentation so it pertains to their patient on their date of service, is considered clinical plagiarism. Merriam-Webster's definition of the word "plagiarize" is "to steal and pass off (the ideas or words of another) as one's own: use (another's production) without crediting the source," and also "to commit literary theft: present as new and original an idea or product derived from an existing source."
As an auditor, when these situations are encountered, it poses the question, "How much work did this provider do on this date of service?"
Was it medically necessary for this provider to see this patient after 8 days as an inpatient and perform a comprehensive exam that has not changed, when the assessment says the patient is stable? It is our job to review encounters to verify that they support the services reported and to educate clinicians on documentation best practices. Proactive audits are a good way to identify these situations and allow for timely education to prevent future problems. Remember, best practice is to report the work done at the time of service while illustrating the complexity of caring for the patient.
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