We always strive for completeness of clinical documentation. It is important to remind providers and practice managers to heed a warning from an OIG initiative; the OIG has announced their intent to audit healthcare organizations receiving meaningful use payments as part of the FY2013 operations work-plan for potential fraudulent practices to investigate:
- Copy-and-paste activities (copy information from one patient to the next, from one encounter to the next)
- Organization coding practices to include policies promoting cut and paste
- Documentation practices specific to evaluation and management leveling
Here are my thoughts…
Copy-and-Paste practices may complete documentation quicker but, likely not intentional, have misrepresented the patient’s admission, care and claim submission. The OIG and payers are taking notice.
Auditors can easily pick up on the cloning of notes regardless of the location of services. Carried over or pre-populated documentation can lead to contradictions in a patient’s complaint, review of systems, physical exam and medical decision making. A provider never wants to be challenged if their documentation is authentic.
Take the time to document what you are managing – be complete and concise. Edit and review your documentation carefully. Make sure it is an accurate assessment of what work has been performed and that it reflects the current patient status. It will benefit quality measures, decrease exposure risk of payment retraction and audits.
What are your thoughts?