When we go to the doctor, someone puts notes into our file. If you see these notes, some entires might be strikingly similar. This is called cloned notes. Below in this week’s Industry Hot Buttons, we go over cloned notes and how they can be an issue. Read the article below to find out more!
Cloned notes, as defined by CMS, are entries in a patient’s health record that are identical or strikingly similar to other entries in the same or another patient’s health record.
EMR’s have made the lives of health industry professionals easier in so many ways. Unfortunately, they have also created a few headaches.
Many people may not have known him until his recent passing, but Lawrence “Larry” Tesler was one of the computer scientists who created the “copy/paste” function.
This function has completely changed the way that each of us uses technology every day and is a function some of us would be lost without, myself included.
The problem is when this is over-utilized in the medical record. It leads to contradictions in our notes, unnecessary information, and often times the needed and pertinent information is left out.
As far back as 2013 the OIG has had Cloned Notes on their radar. It can lead to loss of integrity of the documentation and even damage the trustworthiness of the clinicians.
In a recent issue of Healthcare Business Monthly from the AAPC, an article entitled “Skirting the Dangers of Cloned Notes in Healthcare Practices”, writer Terry A. Fletcher explores the issues surrounding this and the risks it puts your practices at.