Do You Clone Data?
One of the reasons that electronic health records (EHRs) are helpful is that they make accessing and reviewing information much more rapid... and legible! I couldn't imagine having to read my own handwriting, let alone someone else's! As for evaluating prior records and history information, data can be easily reviewed, stable findings can be brought forward in the chart and new information can be updated.
This history review can speed data entry, but be cautious about copying everything forward for every encounter wholesale. When you review data and copy information forward in the record, that is known as data cloning, which can be a legitimate function of an EHR. Remember though, that every component of each encounter needs to be specific to care for a specific clinical situation that also relates to the patient's chief complaint, so data copied forward should be pertinent to that encounter. It is also important to understand that no two patient encounters should look exactly alike, again each encounter should reflect the specific clinical situation.
Some things to consider to help avoid inappropriately cloning clinical notes which could lead to false documentation include:
When you are importing information from a patient's previous encounter be sure that the information is still accurate to the current:
Medical Decision Making
You are responsible for data in the chart so be sure to review and edit all the elements for the current visit - make sure there are no conflicting statements in the chart
An example of this could be that a standard statement in the chart noting a "clear cornea OU" gets copied forward for an encounter where the clinician also documents "2+ SPK inferiorly OU"
The result would look like: "clear cornea OU, 2+SPK inferiorly OU"
Utilize accurate and ethical documentation – don’t just do something because it is habit or to "upcode"
Be thorough and specific when documenting
Review the chart to make sure that what is documented is also accurate to that specific encounter prior to closing or finalizing an examination
Minimize habitual, routine copy and paste functions unless things are truly the exact same
Bottom Line: Cloning data can be acceptable if you are doing it appropriately and ethically.
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Have a great week! - Chris