Health Information Management

Q&A: Pulling ancillary documentation forward in EHR

CDI Strategies, October 10, 2013

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Q: With electronic health records, many times the attending provider will “pull” the pathology or radiology report into their note and sign the note. What further documentation would be needed in order to code from this, which is now part of the attending provider’s note but was generated by a pathologist or radiologist?

A: I’m not sure if any additional documentation would be required.  I would actually encourage this practice if this is the only way the documentation gets added to the medical record. The fact that the provider pulled the information into their note demonstrates that they reviewed the information and, in my opinion, validates the finding. Most providers feel (and I tend to agree) that it is redundant for them to restate diagnostic findings. Remember, however, inpatient coding guidelines do not allow the assignment of codes from non-treating providers, which is why the attending (treating medical team) needs to restate the finding.

With today’s technology is it so much easier for diagnostics to be interpreted by an “expert,” so the attending is less likely to provide their own interpretation, which could make them vulnerable to litigation. Ideally, EHR software could automatically pull forward the findings of any diagnostics allowing the provider to accept, decline, or modify the findings and include them easily and efficiently into their discharge summary. There is so much “noise” in the EHR it can be difficult for providers to sift through all of it effectively.

The reality of healthcare is it is an interdisciplinary, team concept that requires collaboration between hospitalists and specialty providers. To that end, we need to encourage easier communication among all members of the team and consider the contributions of all.  CMS stresses that you should consider the documentation of all providers when assigning diagnoses and/or supporting the level of care.

I know there are a lot of concerns regarding copy/paste in the EHR. I agree it is problematic when copy and paste is used as a short cut rather than providing both patient-specific and episode-of-care specific information. I agree that copy/paste boiler plates are not preferable as each record should be unique to the patient. However, I don’t really see how copy and pasting in this instance would be any different than restating the findings verbatim, it is just a quicker method, but shouldn’t make it any less valid.

Editor’s Note: Cheryl Ericson, MS, RN, CCDS, CDIP, AHIMA Approved ICD-10-CM/PCS Trainer, CDI Education Director for HCPro Inc., answered this question. Contact her at cericson@hcpro.com. For information regarding CDI Boot Camps offered by HCPro visit www.hcprobootcamps.com/courses/10040/overview. This article originally published on the ACDIS Blog



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