Health Information Management

Q&A: Taking a stand on medical record copy and paste functionality

CDI Strategies, January 8, 2015

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Q: What is ACDIS’ stance on physicians cutting and pasting the entire radiology report into their progress note? Are we allowed to take diagnoses from this documentation? Can the physician cut and paste the radiological findings from the report into their progress notes? Or is this, in both instances, just a good query opportunity?

A: If I had my way the copy/paste function would be turned off (and I have heard a few organizations doing just that) but I am not the one making the rules. Now, my answer is not going to be clearly black and white.

If the provider includes an MRI interpretation, or even the latest lab result,s but also offers a summary or interpretation of his or her own, a query may not be necessary. The statement can even be as simple as: “I agree with the radiologist’s finding of,” or “these lab results support the diagnosis of.”

But, if the findings or results simply pasted into the medical record without any explanation then the CDI team should query to clarify. I earned my CDI chops at the elbows of some very conservative coders and know they would wish for more distinct clarification from the provider.

That said, organizations interpret this practice differently. Ask your coding supervisor or manager to better understand your organization’s policies around the electronic medical record, specifically the cut and paste functionality. Consistency within the organization is important, and the CDI team should be aware of any such policies to communicate those back out to the medical staff during regular, ongoing education.

Additionally, ACDIS did publish a position paper “Electronic health records and the role of the CDI specialist,” in its October 2013 edition of the CDI Journal.

Hope this helps!

Editor’s Note: Laurie L. Prescott, MSN, RN, CCDS, CDIP, is a CDI Education Specialist with HCPro Inc., in Danvers, Mass., and a lead instructor for its CDI-related Boot Camps. For more information regarding upcoming Boot Camp dates and locations visit www.hcprobootcamps.com/courses/10040/location-dates.



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