Q: As a traveling consultant, I review many types of inpatient hospital records. As hospitals have implemented electronic health records (EHR), I’ve seen documentation worsen. The ability to cut and paste information in the record has compromised coding accuracy. It has also increased the volume of queries, which frustrates physicians.
For example, a physician performs a history and physical (H&P) in his or her office one week prior to admitting a patient to the hospital. The first progress note in the EHR—as well as each subsequent progress note—includes the exact same documentation. This documentation, which continues for four days while the patient is in the hospital, is clearly based on the original H&P. Obviously, the documentation has been copied and pasted from one note to another. Even the patient’s vital signs remain exactly the same as they were in the physician’s office.
Coders have no way of knowing whether physicians who treat the patient in the hospital agree with any test findings because residents simply cut and paste the results in each subsequent progress note. Residents claim that they do this solely for the attending physician’s convenience. Clinical documentation improvement (CDI) specialists don’t address the problem because they are more focused on determining the accuracy of the MS-DRG.
Is there a solution that will keep physicians, coders, and CDI specialists all on the same page?
A: Unfortunately, there isn’t a quick—or easy—solution for this issue.
It’s ironic that the EHR increases the volume of queries, given the fact that EHR technology has been touted for being able to prompt providers for accurate documentation in real-time as they enter data into the record. Many organizations are disabling the cut and paste option, as they have discovered an increase in inaccuracies in the medical record.
As we move forward, I anticipate increased scrutiny of documentation that has been copied and pasted. I hope that CMS and/or the other Cooperating Parties will publish guidance regarding the appropriate and inappropriate use of this type of documentation.
In the meantime, CDI specialists must determine how they will handle the issue. In my experience, most CDI specialists report copy and paste problems directly to the provider and then work with that provider to clarify the documentation. It’s unfortunate that you’ve encountered CDI specialists who don’t believe that it’s under their purview to address documentation that has been copied and pasted. On the other hand, the HIM department—rather than CDI—may be addressing it directly if it’s considered a general documentation problem rather than something clinically-related.
Perhaps the best approach is to develop a policy in conjunction with the medical executive committee regarding the use of copy and paste documentation within the organization. Physician accountability is crucial. Unfortunately, many organizations are unwilling to hold providers accountable for abusing copy and paste functionality. Hospital leadership must clearly state its expectations regarding the use of copy and paste documentation and support the efforts of the HIM and CDI departments. This includes implementing disciplinary processes for repeat offenders.
Elements of this policy should include a point person to whom staff can refer providers and/or examples of records with documentation that has clearly been copied and pasted. The compliance and quality departments should provide education to physicians, bedside nurses, and CDI staff regarding the risks associated with documentation that has been copied and pasted
Professional coding staff should help to develop the policy as well as educate providers. They are best suited for this role, as they have access to hospital staff, and they also have a vested interest in preventing documentation that can negatively affect coding and billing.
Editor’s note: Cheryl Ericson, MS, RN, CCDS, CDIP, AHIMA Approved ICD-10-CM/PCS Trainer and CDI education director at HCPro, Inc. in Danvers, Mass. answered this question.
This answer was provided based on limited information submitted to JustCoding. Be sure to review all documentation specific to your own individual scenario before determining appropriate code assignment.
Need expert coding advice? Submit your question to Senior Managing Editor Michelle Leppert, CPC, at mleppert@hcpro.com, and we’ll do our best to get an answer for you.