The practice of cloned (or copy and pasted) documentation is a significant issue in the use of Electronic Health Records (EHRs). AMA found in a recent study that only 18% of medical records documentation was newly entered.
Terry discusses how the use of cloned notations and documentation can damage the integrity and trustworthiness of a medical record: and also that of a physician.
The growing abuse of this practice or “EHR feature” is an area of government audit focus. We need to act on how this can affect the safety and quality of care for patients, as well as the potential for fraud and abuse allegations.
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BS, CPC, CCC, CEMC, SCP-CA, ACS-CA, CCS-P, CCS, CMSCS, CMCS, CMC, QMGC, QMCRC
Ms. Terry Fletcher is a healthcare coding and billing consultant based in Southern California. With over 30-years experience, Ms. Fletcher teaches over 100 specialty coding Seminars, Teleconferences and Webinars every year. You can find her CodeCast™ podcast series, focusing on Physician Coding, Billing, Reimbursement, compliance, and Medical industry revenue opportunities, on iTunes, Stitcher, TuneIn, and Google Play.