Electronic medical records (EMR), if used correctly, can enhance patient care and provide a better workflow by allowing for the creation of exam templates, drop-down queues and autoprompts to hasten the documentation process.
The EMR “copy and paste” function allows clinicians to easily incorporate reports in a single progress note. While this function may appear to save time, it can potentially compromise the integrity of the medical record by pulling forward inaccurate or outdated information.
The Centers for Medicare & Medicaid Services (CMS), the governing body for most insurance plans, has clear EMR guidelines. The independent Medicare Administrative Contractor that reviews charts for the appropriateness of service has been directed by the CMS to identify “suspected fraud, including inappropriate copying of health information” under the Benefit Integrity/Medical Review Determinations mandate. However, it’s apparent providers aren’t always adhering to these guidelines.
The American Medical Association released a study in August 2017 in which it analyzed 23,630 notes written by 460 clinicians. The study found “In a typical note, 18% of the text was manually entered; 46%, copied; and 36%, imported.”
In addition, the Office of Inspector General reviews duplication standards in charting and has said the use of duplicate entries “may be associated with improper payments.” Copy-and-paste errors can result not only in Medicare and other insurance companies denying or recouping payments, but can invite case reviews and create legal liabilities.
There are ways to improve your EMR documentation and avoid copying and pasting:
- Document each patient encounter accurately. The old adage of “it wasn’t documented, it wasn’t done” still holds true, even with EMRs. The validity of the entire patient’s medical record, along with each encounter as complete and accurate, is vital to offsetting potential fraud and abuse accusations.
- Provide comprehensive training and education on proper documentation to all EMR users.
- Work closely with your vendor in setting up your system to work well in all aspects of documentation guidelines.
- Monitor compliance and enforce policies and procedures regarding use of copy and paste.
Although copy and paste is tempting, all health care providers, large and small, must continually focus on the preservation and integrity of their patients’ EMRs.