{"id":518,"date":"2014-01-09T19:17:45","date_gmt":"2014-01-09T23:17:45","guid":{"rendered":"http:\/\/www.eclipsepracticemanagementsoftware.com\/blog\/?p=518"},"modified":"2014-01-09T20:49:28","modified_gmt":"2014-01-10T00:49:28","slug":"auditors-are-actively-looking-for-documentation-shortcuts","status":"publish","type":"post","link":"http:\/\/eclipsepracticemanagementsoftware.com\/blog\/2014\/01\/09\/auditors-are-actively-looking-for-documentation-shortcuts\/","title":{"rendered":"Auditors Are Actively Looking For Documentation Shortcuts"},"content":{"rendered":"

Technology can make clinical documentation faster & more efficient. But beware the temptation \u2013 even when the means are at hand \u2013 to take these time saving ideals too far. There may be consequences.<\/p>\n

The Department of Health & Human Services (DHHS) has narrowed their EHR focus over the past few years to specific concepts. First, let\u2019s review a quote from congressional testimony in July, 2011:<\/p>\n

\u201cThe very aspects of EHRs that make a physician\u2019s job easier\u2014cut-and-paste features and templates\u2014can also be used to fabricate information that results in improper payments and leaves inaccurate, and therefore potentially dangerous, information in the patient record.\u201d<\/p><\/blockquote>\n

So\u2026 who said that and why should you care? That was part of 11 pages of testimony from the Chief Counsel for the Office of the Inspector General (OIG), DHHS. Interestingly, it\u2019s echoed in a newly released OIG report that was the subject of a January 8, 2014 NY Times article<\/span><\/a>.<\/p>\n

When I occasionally explain to clients that \u2013 for their protection \u2013 we won\u2019t provide the means to copy their Encounters (SOAP) between patients, they\u2019re rarely happy. And often, they don\u2019t recognize the danger that lurks just around the corner \u2013 a danger we endeavor to protect them from.<\/p>\n

Perhaps\u2026 if they\u2019d been aware of the above 2011 testimony, they might have second thoughts. When you copy documentation between patients to save time, it\u2019s likely that you\u2019re copying more than you actually need. Then, you go back & fix the new note by deleting or updating irrelevant information. However, multiple studies \u2013 and your own experience \u2013 should help you reach the conclusion that you\u2019re not perfect in this regard. Mistakes happen, especially when you\u2019re in a hurry and\/or multi-tasking. At one time or another, most of us have read back over older prose and found mistakes that escaped our original edits.<\/p>\n

The new report released Wednesday simply emphasizes OIG\u2019s focus on \u201ccopy & paste\u201d along with its potential for fraud. Good documentation habits can save you from myriad problems \u2013 or just one. And this is the type of issue which is unlikely to be noticed unless or until someone else reviews your documentation.<\/p>\n

ECLIPSE helps you maintain smart, audit safe habits. If an investigator even brings up the issue as a possibility, you can simply point out that your software specifically disallows it. Yet, ECLIPSE makes it easy to move forward appropriate aspects of a patient\u2019s prior visit on an individual basis. By the way, if you think a narrative based computer program that juggles phrases to make the exact same information look different to auditors is fooling anyone, you\u2019re delusional. Ask anyone who reviews documentation.<\/p>\n

And don\u2019t forget\u2026 DHHS uses computers too. Just like you. They\u2019re doing their best to expose fraud and protect patients on multiple fronts, as well as help combat potential security issues. And one goal is to step up the volume of reviews:<\/p>\n

\u201cWe recommended that the Department conduct compliance reviews to ensure that Security Rule controls are in place and operating as intended to protect personal health information\u201d<\/p><\/blockquote>\n

So, with a higher emphasis on reviews and given the potential downfalls, there are likely myriad ways to speed up your documentation without resorting to copy & paste or as they\u2019ve come to be called: \u201ccloned notes.\u201d ECLIPSE helps you reach performance oriented objectives using government preferred \u201cstructured data\u201d while saving you from some of the pitfalls that other documentation software may be exposing you to.<\/p>\n

 <\/p>\n","protected":false},"excerpt":{"rendered":"

Technology can make clinical documentation faster & more efficient. But beware the temptation \u2013 even when the means are at hand \u2013 to take these time saving ideals too far. There may be consequences. 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