Over documentation is the practice of inserting false or irrelevant information to create the appearance of support for billing higher-level services. Some EMR technologies auto-populate fields when using templates built into the system. Other systems generate extensive documentation based on a single click of a checkbox if not appropriately edited by the provider. Features that are not properly utilized can produce information suggesting that the practitioner performed more comprehensive services than were actually rendered.
Copy-pasting, also known as cloning, enables users to select information from one source and replicate it in another location. When doctors, nurses, or other clinicians copy-paste information but fail to update it or ensure accuracy, inaccurate information may be entered into the patient's medical record, and inappropriate charges may be billed to patients and third-party healthcare payers. Furthermore, inappropriate copy-pasting could facilitate attempts to inflate claims and duplicate or create fraudulent claims.
Facilities should have policies in place to ensure doctors are not inappropriately using copy and paste. However, supervising physicians review charts periodically to ensure clinicians are not relying too heavily on this technique. The billing and coding department should also review charts to make sure everything is supported by the documentation.
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