The act of "copy and paste" or pulling forward the information from past hospital visits can save time but result in misrepresenting a patient's stay and fraudulent submission for reimbursement, according to an article in the June issue of the Journal of AHIMA. Documentation auditors say they have witnessed this practice occurring, but it is just now reaching the payers' radar screens. Health information management (HIM) professionals should be on the look out for these electronic health record (EHR) documentation bad habits because the practice can lead to serious consequences for both patients and facilities.

Scribing or authenticating notes made by another person is also misrepresentation that can be construed as a fraudulent act. The article states that scribing has long been a practice on paper charts, but it can be harder to recognize in some EHR systems.

Bad Habits in Electronic Documentation explains that although poor documentation practices are possible in EHRs, it does not mean that the systems generally lead to overall poor documentation or promote fraud. Also highlighted is a report that states EHRs are the key to controlling fraud costs because of their audit trail capacities and other technology features.
Read the complete article in the June issue of the Journal of AHIMA or online at journal.ahima.org.

About AHIMA

The American Health Information Management Association is America's leading professional society whose mission is to "improve healthcare by advancing best practices and standards for health information management and [serve as] the trusted source for education, research and professional credentialing." AHIMA represents more than 51,000 specially educated HIM professionals who serve healthcare and the public by managing, analyzing and utilizing data vital for health system management.

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