by McKenzie Harrison, CPMA
November 3rd, 2016
When an entry in the medical record is worded similar to or exactly as previous records, or when parts of the medical record are exactly the same from patient to patient, this is called Medical Cloning. When this occurs, the documentation does not meet the requirements of medical necessity due to the lack of specific and individual information.
Electronic Health Records (EHR's) have many functions that can be very beneficial to providers, when used properly. One of the functions used in EHRs is a "copy and paste" function. This allows past notes or a portion of past notes to be used in the current visit. This can become a problem when the physician is copying a section from a previous note and is not paying close attention to what he or she is copying. This can result in copying and pasting information that is not current, such as copying a patient's complaint from a previous visit that has resolved and is not active, copying medications that are no longer current, or copying the patients’ vitals. When this happens, it can affect the safety of the patient and could cause a delay in diagnosis.
There are certain parts of previous encounters that can be copied and used during a current visit. Past histories, chronic conditions, allergies and medications can be copied, but if they are not confirmed as correct by the patient this could result in false information and could continue to be copied wrong at each visit. This could cause big problems. If a patient is being seen and the medications are copied without checking to see if any new medications need to be added, or which medications are no longer current, could cause the physician to prescribe a medication that may have potential harmful side effects when taken with a medication they do not have updated.
While cloning can be obvious, in some cases it can also be harder to catch. Medical cloning from patient to patient is something that is easier to miss if not careful. An example of this is when a patient with a chief complaint of a "cough" and a patient with a chief complaint of "knee pain" have the exact same Review of Systems. These are most often because of the use of Macros or Templates that are inserted without editing, which can contain things that were not asked or done during the visit. If you notice a comprehensive exam is done at every patient encounter and is worded the same, this could be the result in medical cloning and can result in upcoding. This could also be an example of over documenting. Over documenting is when inserting false documents or documents that are irrelevant to the encounter is used so it can support billing a higher level of service.
These functions are overused by providers because of their ease and quickness. Without proper education, these functions can cause more harm than good to both the patients and providers. Simply reviewing items that have been copied or templates that have been used can reduce the risks associated with using these functions.