Auditors Are Actively Looking For Documentation Shortcuts

Technology can make clinical documentation faster & more efficient. But beware the temptation – even when the means are at hand – to take these time saving ideals too far. There may be consequences.

The Department of Health & Human Services (DHHS) has narrowed their EHR focus over the past few years to specific concepts. First, let’s review a quote from congressional testimony in July, 2011:

“The very aspects of EHRs that make a physician’s job easier—cut-and-paste features and templates—can also be used to fabricate information that results in improper payments and leaves inaccurate, and therefore potentially dangerous, information in the patient record.”

So… who said that and why should you care? That was part of 11 pages of testimony from the Chief Counsel for the Office of the Inspector General (OIG), DHHS. Interestingly, it’s echoed in a newly released OIG report that was the subject of a January 8, 2014 NY Times article.

When I occasionally explain to clients that – for their protection – we won’t provide the means to copy their Encounters (SOAP) between patients, they’re rarely happy. And often, they don’t recognize the danger that lurks just around the corner – a danger we endeavor to protect them from.

Perhaps… if they’d been aware of the above 2011 testimony, they might have second thoughts. When you copy documentation between patients to save time, it’s likely that you’re copying more than you actually need. Then, you go back & fix the new note by deleting or updating irrelevant information. However, multiple studies – and your own experience – should help you reach the conclusion that you’re not perfect in this regard. Mistakes happen, especially when you’re in a hurry and/or multi-tasking. At one time or another, most of us have read back over older prose and found mistakes that escaped our original edits.

The new report released Wednesday simply emphasizes OIG’s focus on “copy & paste” along with its potential for fraud. Good documentation habits can save you from myriad problems – or just one. And this is the type of issue which is unlikely to be noticed unless or until someone else reviews your documentation.

ECLIPSE helps you maintain smart, audit safe habits. If an investigator even brings up the issue as a possibility, you can simply point out that your software specifically disallows it. Yet, ECLIPSE makes it easy to move forward appropriate aspects of a patient’s prior visit on an individual basis. By the way, if you think a narrative based computer program that juggles phrases to make the exact same information look different to auditors is fooling anyone, you’re delusional. Ask anyone who reviews documentation.

And don’t forget… DHHS uses computers too. Just like you. They’re doing their best to expose fraud and protect patients on multiple fronts, as well as help combat potential security issues. And one goal is to step up the volume of reviews:

“We recommended that the Department conduct compliance reviews to ensure that Security Rule controls are in place and operating as intended to protect personal health information”

So, with a higher emphasis on reviews and given the potential downfalls, there are likely myriad ways to speed up your documentation without resorting to copy & paste or as they’ve come to be called: “cloned notes.” ECLIPSE helps you reach performance oriented objectives using government preferred “structured data” while saving you from some of the pitfalls that other documentation software may be exposing you to.

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