Do Not Adopt Shortcut Documentation! It Hurts Your Patients And Payments!

Due to hectic work schedules, physicians choose time saving and easy procedures. EMRs have paved the way for smarter and quicker documentation. But everything comes with a price!

Is your transcript the next “Dolly”?!

The time saving process known as “Cloning” is one of the features that make EHRs so popular. The physicians think that there is nothing wrong in copying patients’ notes, recklessly. This can lead to huge penalties, inaccurate patient information and most importantly, patients’ lives are at risk!

So who suffers the most?

The priority is patient’s appropriate health record. It is the patient who suffers due to “copy and paste” methods. Due to poor documentation treatment plans can go hay wire. During subsequent visits the physician may start from the ground level as in the first visit, thanks to outdated data.

The department of Health and Human Services (HHS) has taken a firm stance against cloning; HHS secretary Kathleen Sebelius issued a letter, warning against copy pasting records, in September 2012. A recent study claims that 78% of physicians copy and paste more than a fifth of their patient notes!

So what is the pain in it! Why do the auditors and the payers condemn it?

The fear which haunts payers and auditors is that physicians may file duplicate or inaccurate claims using cloned notes. It may be on purpose, by accident or by using a higher billing code which is not needed, from one visit to the other. Simply pasting prior information into new fields may put providers at risk as every bit of detail is going to be under the scanner.

What are the results of cloning?


By simply clicking around EHRs, physicians do not double check for typos, so if there is a typo in one note it gets spread indefinitely or transferred to another record. Physicians are going to be in a lot of hot water if discontinued medication or a newer treatment plan is not mentioned in the patients’ records. This leads to loss of critical and timely information about a case.

The CMS has adopted the idea of personalised medicine by taking into account the increased number of improper and inflated payments. The idea of cloning doesn’t fit into the healthcare business with physician and patient relying on technology to communicate. With ICD-10 on the shore, more accurate medical information is needed. Or, coders would be at loss!

The use of technology for quick documentation and overbilling


According to a report by The Newyork Times although the government has spent more than $22billion for doctors to adopt EHRs, it has failed to prevent the technology from being used for inflating costs and overbilling. The report released from the Office of the Inspector General  for the Health and Human services department is the second in two months to warn about the ambitious federal program aimed at adopting EHRs to get rid of paper work.

“As E.H.R. adoption has increased, so has its involvement in our cases,” said Michael Cohen, an inspector at the oversight agency’s investigations office, which is in-charge of investigating, health care fraud in government programs.

So how can this bad habit be broken??


Getting out of the comfort zone of copy and paste feature is very tough, it’s not easy for the providers to get out of it until the payers and the auditors go tough on documentation. The focus should be on adopting appropriate measures for proper documentation. Better understanding of the EHRS which will take care of the patient’s next visit.

Proper guidance and awareness campaigns can help physicians accept that the EHRs are meant for documentation tools and not for cloning. It is always better to be safe than to repent later!


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