Copy & Paste - Foe or Ally

The electronic health record can be the physician’s foe or opponent, depending upon how the record is used and the information charted. The benefits of the EHR are vast including allowing multiple user access, the ability to easily see a patient’s longitudinal history and treatment over time, facilitation of coordinated care, use of order sets and reminders, providing of alerts to prevent medical errors and drug-drug interactions to name just a few. One commonly highly touted benefit of  EHRs is to reduce the administrative burden of documentation and charting by allowing “Copy and Paste” also known as “Carry Forward.”

Copy and Paste if used appropriately and compliantly can help the physician reduce the amount of time doctoring in front of the computer, allowing the physician to devote more precious time doctoring with the patient. Less screen time promotes efficiency, permitting the physician to work smarter, not harder. EHRs are often not structured and set up with ease of functionality with physicians developing workarounds and shortcuts including copying and pasting as part of a plan to circumvent excessive point-and-click that constrains physicians’ workflow efficiency.

Proper Use of Copy and Paste

Proper use of copy and paste includes the following:

• Do not copy and paste the subjective portion of the record in the progress note. The subjective or “Interval History” represents any updates, clinical changes, or development of new problems from the previous day.  This is where the physician records the patient's health updates specifically focusing on changes or new developments that occurred from the previous day, essentially capturing only the information that has changed from the previous day’s encounter, without repeating or recapitulating the History of the Present Illness copied and pasted from the admission H & P.
• Do not Copy and Paste the General Portion of the Exam. Remember, this is your time to present, capture, and reflect on what the patient looks like clinically when walking into the patient's room. Do NOT copy and paste “alert, oriented x 3 in no acute distress, non-toxic appearing."
• It is perfectly okay to copy and paste diagnosis from one day to the next with a few caveats. Copy and paste all clinically relevant diagnoses under active management, listing and sequencing acute conditions that occasion or impact the management of the acute conditions first. Be certain to sequence the diagnoses in the assessment with the acute conditions still under active management first. Those conditions that occasioned the admission that have been resolved should be sequenced secondary, documented as “resolved” and continued until discharge, and included in the discharge summary. The main diagnoses still requiring hospitalization can change from one day to the next; acute hypoxemic respiratory failure with acute exacerbation of COPD can both occasion the admission but on day two the acute hypoxemic respiratory failure may have resolved leaving the first listed diagnosis to be still acute hypoxemic respiratory failure.
• Those conditions requiring hospitalization must include a statement whether the condition is improving, slowly improving, still about the same, or taking a turn for the worse. This statement must be supported by the capture and reporting of clinical data, clinical results, observation of the patient, explicit objective information capturing your clinical judgment, and any related changes in the plan of care. It is simply not sufficient to state “improving, “doing better,” or “responding to treatment.”
  
  

Remember that a medical record is a communication tool used to capture and report patient care; your clinical thoughts, clinical judgment, medical decisions, and your adherence to standards of care impact and can minimize medico-legal risk. The Doctor’s Company, the largest physician-owned malpractice carrier in the United States, has identified in a closed claim review of malpractice cases for the time 2017-2021, that nearly a quarter of paid malpractice claims were a result of improper excessive copy and paste.

Key point:

All documentation in the medical record must be specific to the patient and her/his situation at the time of the encounter. Cloning of documentation is considered a misrepresentation of the medical necessity requirement for coverage of services. Identification of this type of documentation will lead to the denial of services for lack of medical necessity and recoupment of all overpayments made.

• See the article from Palmetto GBA for more detailed information on Cloned Documentation

• https://www.palmettogba.com/palmetto/jma.nsf/DID/TRUFF8OZ3J#l

Be judicious in the use of Copy and Paste. Use it sparingly and properly. Appropriate compliant charting and use of Copy and Paste necessitates “Copy, Paste. Update, Edit, Review, and Sign.”

Please see the article above from Palmetto GBA, the Medicare Advantage Contractor in NC, that processes and audits claims for compliance with Medicare regulations governing, documentation, coding, billing, and medical necessity. Don’t be a victim of improper copy and paste contributing to unnecessary payer denials or costly financial recoupments, subjecting the physician to potential Medicare review and Targeted Probe and Education activities.

Glenn Krauss is the is a well-recognized & respected subject matter expert in the revenue cycle with an emphasis & focus upon collaborating & working closely with physicians in promoting, advocating for, educating & achieving sustainable improvement in clinical documentation that accurately reflects & reports the communication of fully informed coordinated patient care. He recognizes the importance of complete documentation in denials avoidance.