Confidentiality, Privacy and Security

Copy Forward HPI--Ok if add interval history?

  • 1.  Copy Forward HPI--Ok if add interval history?

    Posted 10-01-2019 17:03

    Good afternoon -

    I have yet ANOTHER question!  I recently received a review from our state Medicaid for one of our providers.  The review indicated "PATIENT EXAMS WERE NEARLY IDENTICAL VISIT TO VISIT."  Sure enough, it looked the provider was copying forward the entire HPI, so we issued a refund.  However, the auditor here insists they can pull forward HPI as long as they add the interval history, and it is unique to that visit.  The interval history does seem to be unique, but I can't find any documentation to support that.

    Does anyone have an opinion about this?
    Also, does anyone know if copy forward HPI would be ok if  including a confirming statement which says, "NO CHANGE IN THE PAST MIDECIAL HISTORY, FAMILY HISTORY, AND SOCIAL HISTORY FROM THE VISIT DATE MM/DD/YY."

    Thank you to this wonderful group of people for all of your help!

    Sarah



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    Sarah Jackson
    Compliance Manager
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  • 2.  RE: Copy Forward HPI--Ok if add interval history?

    Posted 10-01-2019 18:35
    Hello Sarah,
    I read in my Health Information book that it is dangerous to copy and paste regardless of the statement at the end saying "no change in past...". This practice could reduce the integrity of the medical record. The copy and pasted info might have outdated, inaccurate info. Also according to The Health Information Management Technology, An Applied Approach 5th addition by Nanette Sayles, this practice could have redundant information which makes it difficult to identify the current info., inability to identify the author or intent of the documentation, inability to identify when the document was first created and could lead to propagation of false info, internally inconsistent progress notes and unnecessarily lengthy progress notes.
    I hope this helps.
    Donna Doyle
    Student at Monroe Community College
    Rochester, NY

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    Donna Doyle
    Sales Associate
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  • 3.  RE: Copy Forward HPI--Ok if add interval history?

    Posted 10-03-2019 13:59
    Sarah,

    Copy and paste, or "copy forward", is a reality with today's electronic health record capabilities.  Clinicians like it because of the time savings, but it is fraught with problems related to the integrity of the medical record.  Some facilities may not allow this functionality to be activated in their EHRs, but I don't believe they are the majority.

    Concerning your question about adding  "No change" statement,  I don't see that this would be necessary as the signer of each entry is responsible for all of the content of his or her documentation, whether the content of the documentation is original, or created using Copy Forward.  In other words, each clinician must review information created using Copy Forward for accuracy and completeness and must edit the information, as appropriate, with specific attention to removal of elements that are no longer pertinent, inaccurate or are not relevant to the current patient encounter.

    Below are some excerpts from The Joint Commission's article from 2015 that may be helpful as you work with copy and paste issues.  Also, see the Copy Functionality Toolkit in the AHIMA Body of Knowledge for more information about this topic.

    https://www.jointcommission.org/assets/1/23/Quick_Safety_Issue_10.pdf

    AHIMA recommendations (from 2015 article link above):

    • Develop policies and procedures addressing the proper use of the copy-and-paste function (CPF) to assure compliance with governmental, regulatory and industry standards.
    • Address the use of features such as copy-and-paste in the organization's information governance processes.
    • Provide comprehensive training and education on proper use of copy-and-paste to all EHR system users.
    • Monitor compliance and enforce policies and procedures regarding use of copy-and-paste, and institute corrective action as needed

    The Joint Commission recommendations (from 2015 article link above):

    • Work collaboratively with health care providers, medical societies, and others in the organization to carefully balance the benefits of the CPF with the potential risks, and to develop training and education related to the CPF.
    • Have a process where the accuracy of the clinical record is monitored. This process should include a feedback loop to inform health care providers when their documentation is not accurate or is overly redundant.
    • Begin a focused and ongoing professional performance evaluation (OPPE) with specific triggers and measures related to the accuracy of the clinical record.
    • Maintain robust quality review process(es) in which all cases of potential misuse or error due to CPF are evaluated consistently and comprehensively to identify opportunities for improvement in patient safety.


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    Dana DeMasters, MN, RN, CHPS
    Privacy/Security Officer
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