ICD-10 expert Erica Remer, MD, noted the pitfalls of copying and pasting information when it comes to clinical documentation. While it might be tempting to take a shortcut, Dr. Remer said, documenting fresh information is better in the long-run — and will take less time than disputing denials that result from mistakes.
Dr. Remer is a member of the ICD10monitor editorial board and serves on the American College of Physician Advisors board of directors.
Here are her five "don'ts" of documentation practices.
1. Don't repeatedly copy and paste something that has been previously copied and pasted.
Copying and pasting previous interval histories sequentially, day after day, is a pattern to avoid.
2. Don't copy and paste inaccurate information.
Dr. Remer has seen information incorrectly copied and pasted, such as the results of a study done in a prior encounter or treatments that weren't initiated. Spelling and grammatical errors are red flags signaling outdated documentation.
3. Don't copy and paste documentation without removing or editing temporal references.
Be mindful about words such as "today" and "yesterday" — make sure you're accurately documenting exactly when a treatment was administered or physician was consulted.
4. Don't copy and paste someone else's work without attribution.
"This is not lazy documentation; this practice is called fraud," Dr. Remer said.
5. Don't copy and paste superfluous information.
Importing details such as a radiologist's signature line or results from wounds that healed months ago constitute what Dr. Remer calls "note bloat" and make it harder to care for a patient.
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