Imitation may be the sincerest form of flattery--unless it's in a patient's daily notes! Many EHR vendors tout the ability to "clone" or automatically copy patient notes from one patient record to another, or from a patient's initial visit to the follow-up. Is this a time saver, or merely an invitation for an audit?
Apparently, the Office of Inspector General sees this as fertile ground for fraud and abuse. Even if you're doing it with the best of intentions, you're exposing yourself to potential auditors.
Cloned or copied notes can either intentionally or accidentally inflate claims by copying a higher billing code than is accurate or appropriate from one visit to the next Or by repeating a service provided during an initial visit, but not in the follow-up. Even a simple typo or a misclassification ends up getting carried forward indefinitely. It makes your documentation far too repetitive or uniform--both invite suspicion.
Find out by conducting a simple self-audit. Randomly choose ten patient records and see if you can find instances of cloned notes.
And if you do? Stop it. It puts your practice at risk, and it's not sustainable because of the increased specificity required by ICD-10 coming later this year.
The Paperwork System allows for continuity of care in the patient's episode by carrying forward the GOALS you're working with, but allowing you to personalize and specify your patient's presentation at the time of the visit. Quick. Easy. Fast. Low-tech. And COMPLIANT!
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