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