Case Management

The perils of cut-and-paste documentation

Case Management Insider, June 16, 2015

It may sometimes seem easier for a physician to grab a block of prewritten text and paste it into a patient record. But while this quick cut-and-paste may shave a few minutes off initially, it can create some major headaches down the line, says Glenn Krauss, RHIA, BBA, CCS, CCS-P, CPUR, CCDS, C-CDI, an independent revenue cycle consultant in Burlington, Vermont.

Not only is this practice of copying and pasting without updating a note  a questionable billing practice, it also creates the potential for adverse patient outcomes as nicely summarized in a Joint Commission Quick Safety Issue February 2015 titled “Preventing copy-and-paste errors in EHRs,” he says.
 
Cut and paste also contributes to unnecessary case manager stress and additional work. Many case managers find themselves having to go back to the physician frequently in order to get a sense of the patient’s clinical stability; what diagnoses the physician is managing, working-up, or actively considering.  Case managers need this information to converse with third-party payers for continued-stay authorization and to ensure a safe, effective, and efficient discharge plan.
 
While at the recent ACMA conference in Phoenix, Krauss said he informally polled case managers about what their biggest challenges were in efficiently and effectively carrying out their case management duties and responsibilities. “An unequivocal common theme was consistently dealing with poor, insufficient documentation,” he says.
 
When the clear, detailed, and clinically relevant information case managers need is not in the chart, they can’t be efficient or effective, says Krauss. “So when doctors cut and paste information, it makes it harder for case managers to ensure that patients get the care they need while hospitalized as well as post- acute care discharge,” he says.
 
Case managers are on the front lines when it comes to preventing and overcoming this type of documentation problem. Organizations, as The Joint Commission stated in the Safety Issue, should develop a clear policy for cut and paste documentation, if they haven’t already, says Krauss.
 
“Cut and paste is a misrepresentation of the work performed,” says Krauss. “It should be disallowed. It’s not ethical to cut as paste someone’s work and put my name on it,” he said.
 
This is exactly the sentiment of most Medicare Administrative Contractors, including Palmetto GBA, the MAC for Jurisdiction 11, which updated its Medical Cloning Policy October 31, 2014, as follows:
“The word 'cloning' refers to documentation that is worded exactly like previous entries. This may also be referred to as 'cut and paste' or 'carried forward.' Cloned documentation may be handwritten, but generally occurs when using a preprinted template or an Electronic Health Record (EHR). While these methods of documenting are acceptable, it would not be expected the same patient had the same exact problem, symptoms, and required the exact same treatment or the same patient had the same problem/situation on every encounter. 

Cloned documentation does not meet medical necessity requirements for coverage of services. Identification of this type of documentation will lead to denial of services for lack of medical necessity and recoupment of all overpayments made.
 
But avoiding this practice doesn’t mean that physicians need to spend hours toiling over the medical record. Done correctly, solid documentation doesn’t have to be time consuming; taking the time to do it right up front saves a huge amount of time and expense down the line.
 
Proper documentation should include the relevant details to give medical personnel reading the chart the information they need to understand the patient’s medical history, current condition, plans for continued care and workup, progress notes that actually provide and explain the clinical progress of the patient and plans for discharge post- acute care.
 
Getting it right the first time saves time—and helps to promote and ensure high quality care.

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