Health Information Technologies and Processes

EHR Document...Documentation Cloning Audits

  • 1.  EHR Document...Documentation Cloning Audits

    Posted 29 days ago
    The EHR article posted last week (thanks...very helpful!) made me curious how many folks are auditing for physicians that may be cloning or doing "cut and paste" of documentation inconsistent with policy and procedure or documentation practices to support billing.

    In the "old days" this was certainly very labor intensive and time consuming.  With EHRs...one can now literally download the data entry from a physician over whatever time period is getting audited and check all of the downloaded fields for cloning with an extremely high rate of accuracy.

    Looking to compare and contrast if others are auditing and cloning and if you are using primarily a manual method, automated method, or hybrid method that involves both.

    Thanks!

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    Frank Ruelas
    Compliance Professional
    Arizona
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  • 2.  RE: EHR Document...Documentation Cloning Audits

    Posted 22 days ago
    I appreciate this post.  Your statement "With EHRs...one can now literally download the data entry from a physician over whatever time period is getting audited and check all of the downloaded fields for cloning with an extremely high rate of accuracy." has literally got me thinking. I had not thought about exploring that option; however, I am afraid that our EHR will not have this option. At least, I can explore this option. Currently, our audits have been manual and time consuming. Unfortunately, I am still trying to educate the medical staff on the importance of proper cloning/cut and paste.  When your EHR makes it so easy to do, it is hard to get the point across.

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    Susan Borden
    Director Health Information Management and Medical Staff Services
    Cullman Regional Medical Center
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  • 3.  RE: EHR Document...Documentation Cloning Audits

    Posted 22 days ago


    We are also auditing manually.  I would be interested to hear if anyone is on Expanse and has a more automated and efficient process.

    Thanks!

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    Ashley F.
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  • 4.  RE: EHR Document...Documentation Cloning Audits

    Posted 21 days ago
    Here's what can be a challenge...and I experienced this with Meditech, Cerner, and Epic...to name a few.  The way EHRs are set up, they are basically (some simplification) tables that are linked to one another.  What this means is that a query can be written that can pull data from just about EVERY field in these tables.

    The tricky part is finding out someone who knows how to do this on your EHR support/technical team for those fields you are looking to audit for cloning.  When asking...don't necessarily ask someone..."Do you know how to do x?"...as you may get a "no" answer.  Rather, ask who you need to check with to find out if "x" can be done.  This way you can explain what you need with someone who has the techincal familiarity with how the data is organized in the EHR system.

    Good luck!

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    Frank Ruelas
    Compliance Professional
    Arizona
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