Have you ever read a physician office note and thought it was strangely familiar? Or, not just familiar but identical to another note?
Medicare contractors have noted an increased frequency of medical records with identical documentation across services. We will also review multiple E&M services for the same providers and beneficiaries to identify electronic health records (EHR) documentation practices associated with potentially improper payments.
Electronic health records (EHRs) have made it possible to copy and paste documentation from a previous visit, performed by the same or different provider. It is easy to “bring forward” history, exam and assessments and plans documented at a previous note. Sometimes, the record will say, “Reviewed, no changes required,” and sometimes, these sections are just dropped into the note, as if recorded on this day’s visit. Clinicians must and should take advantage of the historical data stored in the medical record, and use shortcuts to save time. However, only certain types of data should be carried forward into a progress note and with limitations.
What’s the problem with copy and paste? There are both clinical and compliance concerns with copy and paste. Clinically, copying the history of the present illness from a previous visit performed by the same or different provider is inaccurate. The history of the present illness should include the reason for today’s visit and a description of the patient’s symptoms since the last visit. The HPI elements include location, severity, duration, quality, timing, context, modifying factors and associated signs and symptoms. That is, how is the patient doing since last seen? Is the treatment helping? What does the patient say is the problem or reason for the visit? This section of the note is unique to the present visit, and may never be copied and pasted from a previous note performed by that provider or another provider.
The HPI and ROS contradict one another This is a problem when the clinician enters a description of the patient’s problems, but the review of systems is either clicked as “normal” or copied from a previous visit when the patient did not have that complaint. This is a too common problem in progress notes documented using an EHR. It not only provides a confusing clinical picture for other physicians and providers who will treat the patient, it calls into question the validity of the entire history section.
It just doesn’t make sense For some notes, when the history section is copied from a previous note, the description of the patient’s symptoms and the timing just doesn’t make sense. This is particularly true when copied from another clinician’s note or if a long time period has elapsed.
But, can’t a clinician use the past medical history? Yes, there is no reason that the past medical, social and family history cannot be carried forward from a previous note, as long as the provider reviews it with the patient. This is a good use of an electronic health record. Some specialties, such as oncology or cardiology, describe the course of the patient’s treatment since diagnosis, and include this in the HPI section. Since the course of the treatment hasn’t changed, they want to copy it from a previous note. Here’s how that looks: “Patient diagnosed in 2008, with cell type XYZ, treated with radiation and three rounds of chemo. Then, in 2009….” This historical data doesn’t change from visit to visit, and may be copied into any section the physician desires: the HPI or the past medical history. (Auditors will count it as past medical history.) However, in addition, the clinician should document the patient’s symptoms (or lack of symptoms) since last seen. Are there side effects of treatment? How is the patient feeling? Those are the elements of the history of the present illness, which may not be copied and brought forward from a previous note.
Family history reviewed, unchanged Great, if the clinician has done so. But, if the section labeled family history is empty, what did the clinician review? It calls into question the validity of all of the copied note.
What about populating today’s note with the information from the last visit, to save time, and just updating it? Dangerous. Of course it is time saving, but it is too easy to forget to update or change one part. I strongly urge clinicians not to populate today’s note with the information from the last visit.
Guard against cloned notes in your practice. If some part of the history is used from a previous visit, the provider must review it with the patient, and indicate that it is unchanged. The Documentation Guidelines don’t give credit for “clicking” on reviewed. The Guidelines state the history doesn’t have to be re-documented, not that the work doesn’t need to be done.