EHR and Documentation

Writing notes“Copy-pasting and over documentation are two easy ways for fraud to occur in EHRs; sometimes, it’s the fault of pre-population by EHRs and sometimes, it’s a lack of oversight from doctors and nurses who enter information via copy-paste and don’t review or correct it.”  wrote Mr. Daniel R. Levinson in an Office of the Inspector General (OIG) report in January 2014. I actually have conducted a number of audits myself and found out that many records were simply clones of each other.  I understand that there are a number of entries required by certified EHRs that may have records looking alike. Yet after reading three records from one Provider I can pretty much tell which records are cloned and which aren’t. There are two issues as it regards to copy paste and cloning:

  1. Overbilling;
  2. Time efficiency.

Personally I’m not against templates and prompts as these helps us become more efficient and potentially remind us of options in the Treatment Plan.  Yet we have to be careful not to cross the threshold between good medicine, canned medicine and fraud.  So my recommendations:

  1. Make sure you review your documentation. You are responsible for it whether you look at it or not so don’t take chances.
  2. Customize each patient record.  Even if you use a template make sure that the uniqueness of each patient and encounter is transparent.