The Compliance Department has received several inquiries from faculty and staff about prepopulating medical records. In July 2014, the Compliance Office and its medical director, Joshua Copel, MD, sent an email to faculty stating that “prepopulating notes is a practice that should be discouraged and should be used only in unusual circumstances.”
Some of the recent inquiries have focused on preparing operative or progress notes ahead of time and revising them after the service has occurred. While this may seem like an efficiency provided by the electronic medical record (EMR), this practice is still highly discouraged.
Some of the pitfalls include retaining information in the note that is not relevant, or that is incorrect or not updated. This is true especially in regards to the physical exam, which may be identical from one visit to the next. In addition, the information pertaining to history copied and pasted from the previous note often leads to “note bloat.”
In September 2012, the federal Department of Justice, and Department of Health and Human Services issued a letter addressing fraud and abuse concerns over certain EMR documentation practices. The letter stated “[a] patient’s care information must be verified individually to ensure accuracy; it cannot be cut and pasted from a different record of the patient, which risks medical errors as well as overpayments.”
In December 2013, the HHS Office of Inspector General produced a report titled, “Not All Recommended Fraud Safeguards Have Been Implemented in Hospital EHR Technology.” This report covered the risks and benefits of the copy-and-paste feature in EMR technology.
Our Medicare contractor in Connecticut, National Government Services, has published an article that states: “Documentation is considered cloned when it is worded exactly like or similar to previous entries. It can also occur when the documentation is exactly the same from patient to patient. Individualized patient notes for each patient encounter are required...cloned documentation will be considered misrepresentation of the medical necessity requirement for coverage of services due to the lack of specific individual information for each unique patient. Identification of this type of documentation will lead to denial of services for lack of medical necessity and the recoupment of all overpayments made.”
In summary, we continue to recommend judicious use of “copy and paste” as it may present a concern for patient safety and is viewed with suspicion by payers. Please address any questions to Judy Harris, director of compliance at 203-785-3868 or judy.harris@yale.edu.