As an HIM professional within Anywhere Hospital’s HIM department, you have been asked to review physician documentation within the hospital’s new EHR system, implemented six months ago. Your goal of the review is to catch any documentation issues early and work with the appropriate hospital leadership to fix those issues.
As you review the documentation within your facility’s EHR, you notice that physicians are utilizing the copy and paste functionality available within the EHR system, allowing physicians to select health record documentation from one source or from one section of the EHR and replicate it in another source or another section of the record. You notice in one particular instance that the health record identifies a patient as a 65-year-old male (as identified during the registration process) but in the progress notes is described as a 25-year-old female who has given birth. Clearly, the physician utilized the copy and paste functionality inappropriately and copied health record information from a health record of a patient who was a 25-year-old female and pasted that information accidentally into a health record of a 65-year-old male.
You find this concerning because this could have patient safety concerns, as well as billing and claims issues and the use of this functionality could open the facility up to potential claims of fraud and abuse by the payer. You take this concern to your leadership and a multidisciplined group of hospital employees including HIM professionals, nurses, physicians, and billing and revenue cycle employees to discuss and fix the problem. There are mixed opinions about the copy and paste functionality. Some individuals feel this feature is a time-saver and a productivity booster while others believe it only opens the hospital up to additional CMS scrutiny.
As the HIM professional, you present the following questions to the group for consideration:
What, if any, are the regulatory requirements or prohibitions to using such a feature within an EHR?
Does the design of the facility’s EHR promote or detract from health record documentation quality and integrity?
Are there any alternatives to this feature that will assist with documentation efficiency?
How would the facility set forth organizational documentation standards related to this feature?