Friday, October 14, 2016

Tips For Great Clinical Documentation Part 4

In the previous post of the series, I highlighted the importance of being consistent when documenting, as the days pass and as the patient’s situation changes. In this post, I am going to mention how creating templates can help and how and why to avoid medical record cloning

Create templates, but avoid medical record cloning.

When providers see patients and document, a sequence of actions occurs that does not vary patient to patient. First the provider sees the record, the new laboratory workup, the past history, then, he or she sees the patient and finally the creation of a new note takes place. This last step also has its own sequence because all different types of notes have defined sections that have to be present for all cases. Creating templates for documentation helps with not forgetting to include the necessary elements of the history and physical, progress note, consultation, discharge summary, postoperative note, etc. In addition to that, a template can make the provider remember to include always certain aspects that may be missed, like a nutritional assessment, for example.

One of the abilities of  electronic health record systems is the ability of being able to import parts of a previous record into a new note. Some information may change little on a day to day basis. The ability of “cut and paste” can lead to medical record cloning if appropriate measures are not taken. Medical record cloning can lead to fraud, in the sense that a chart may contain information that may not represent exactly what happens to the patient in a particular day and and the same time lead to inaccurate billing. In order to avoid medical record cloning physicians using the “cut and paste” technique must make sure that the note is unique for the day, that it reflects what happened in that particular day and that billing is consistent with the content of the note.

Marco A. Ramos MD
Second Medical Opinions PLC

Physician Advisor in Clinical Documentation Improvement

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