Health Information Management

News: MAC says no to documentation cloning

CDI Strategies, October 24, 2013

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If you need evidence to support the contention that physicians shouldn’t copy and paste information about their patients’ conditions from the previous days’ description, look no further than the October 8, weekly E/M tip from Palmetto GBA, Medicare Administrative Contractor (MAC) for Jurisdiction 11, which includes north and south Carolina, Virginia, and West Virginia.

“Always document the chief complaint (CC) and History of Present Illness (HPI) based on the patient's description on that day,” the tip states. “Never copy it from a previous visit. Only use the Review of Systems (ROS) and examination that is relevant to that day's visit.”

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