Health Information Management

News: The perils of cut-and-paste documentation

CDI Strategies, June 25, 2015

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On June 16, a Senate committee examined how to improve electronic health record (EHR) systems, focusing on the physician’s experience which, as CDI specialists know, can be a source of frustration and lack of engagement for physicians.

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 summarized in a Joint Commission Quick Safety Issue from February 2015 titled “Preventing copy-and-paste errors in EHRs,” he says.

Cut-and-paste also contributes to unnecessary stress and additional work. Many CDI specialists find themselves having to go back and query 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. CDI specialists need to obtain the necessary documentation to present the clearest clinical picture. CDI staff may also help spread the word about the concerns of cut-and-paste documentation through education for physicians and other staff.

When the clear, detailed, and clinically relevant information CDI specialists and coders need is not in the chart, they can’t be efficient or effective, says Krauss.

Although copy-paste for documentation has become a commonplace problem with the advent of the EHR, CDI specialists should not position themselves at the forefront of correcting these issues, but rather make physicians and other staff aware of these issues (read the ACDIS position paper on EHRs here.) However, if a diagnosis enters the record inadvertently that is not supported by the documentation, the CDI specialist should query the treating physician.

Editor’s Note: This article was originally published in Case Management Insider.

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