Knowledge Base Article

We all know about the cloning of genetic material (remember Dolly the sheep), but are you aware of the risks associated with the cloning of medical record documentation? This type of “cloning” occurs when each entry in the medical record for a patient or patients is worded exactly alike or similar to previous entries. It is also known as “cut and paste” or “carrying forward” and generally occurs with using a preprinted template or an electronic health record (EHR).

Templates and electronic records offer many benefits, such as increased documentation speed and efficiency, but there are potential risks. The Office of Inspector General (OIG) and several Medicare Administrative Contractors (MACs) have published articles about the use of cloned documentation. Their concerns are that “cloned” documentation can lead to fabricated information, improper payments and corrupted patient records. Several MACs state that “this ‘cloned documentation’ does not meet medical necessity requirements for coverage of services rendered due to the lack of specific, individual information. All documentation in the medical record must be specific to the patient and her/his situation at the time of the encounter.” See the references at the end of this article for specific excerpts from government agencies and contractors.

So, as a hospital, how should you identify “cloned” documentation and what should you do about it?

• It is likely that your medical record coders, clinical documentation improvement staff, and/or case managers can tell you if there are instances of cloned documentation in your medical records.
• To identify problems with repetitive documentation look for contradictory information in the medical record associated with such entries, progress notes that do not change from day to day, and the repetition of typographical errors from note to note.
• Develop a policy addressing the use and controls for carry forward documentation and documentation templates
• Educate physicians and practitioners about the appropriate use of EHR tools and the importance of verifying accurate and complete documentation
• Audit medical records for inappropriate “cloning” and have processes in place to address abuses.

Two excellent articles that address this topic are a reprint of a Report on Medicare Compliance article by AISHealth and an AHIMA article on Documentation Bad Habits.

Medicare Resources

OIG Top Management and Performance Challenges: Integrity and Security of Health Information Systems and Data“Finally, EHRs should facilitate more accurate billing and support better quality of care but, when misused, may promote fraudulent billing or inappropriate care. For example, cut-and-paste features and auto-fill templates can reduce paperwork burdens, but can also be misused to fabricate information, generating improper payments and corrupting patients' records with inaccurate and potentially dangerous information. Similarly, well-designed decision support tools can help physicians select the best care for their patients, but inappropriately designed decision support tools can promote waste and inappropriate care."

Palmetto GBA: Medical Record Cloning“The word 'cloning' refers to documentation that is worded exactly like previous entries. This may also be referred to as 'cut and paste' or 'carried forward.' Cloned documentation may be handwritten, but generally occurs when using a preprinted template or an Electronic Health Record (EHR). While these methods of documenting are acceptable, it would not be expected the same patient had the same exact problem, symptoms, and required the exact same treatment or the same patient had the same problem/situation on every encounter. Cloned documentation does not meet medical necessity requirements for coverage of services. Identification of this type of documentation will lead to denial of services for lack of medical necessity and recoupment of all overpayments made.”

Cahaba GBA: FAQ Medical Reviewregarding cloning“The medical necessity of services preformed must be documented in the medical record and Cahaba GBA would expect to see documentation that supports reasonable and medically necessary services and any changes and or differences in the documentation of the History of Present Illness, Review of System and Physical Examination. The medical record must be authenticated by the provider of services. CMS acceptable signature methods are hand written and electronic signatures. Stamp signatures are not acceptable.”

CGS: Electronic Medical Records Tips“Cloning occurs when medical documentation is exactly the same from beneficiary to beneficiary. It would not be expected that every patient had the exact same problem, symptoms, and required the exact same treatment. This "cloned documentation" does not meet medical necessity requirements for coverage of services rendered due to the lack of specific, individual information. All documentation in the medical record must be specific to the patient and her/his situation at the time of the encounter. Cloning of documentation is considered a misrepresentation of the medical necessity requirement for coverage of services. Identification of this type of documentation will lead to denial of services for lack of medical necessity and recoupment of all overpayments made.”

First Coast: Cloning of Medical Notes“Cloning of Medical Notes: Documentation is considered cloned when each entry in the medical record for a beneficiary is worded exactly like or similar to the previous entries. Cloning also occurs when medical documentation is exactly the same from beneficiary to beneficiary. It would not be expected that every patient had the exact same problem, symptoms, and required the exact same treatment. Cloned documentation does not meet medical necessity requirements for coverage of services rendered due to the lack of specific, individual information. All documentation in the medical record must be specific to the patient and her/his situation at the time of the encounter. Cloning of documentation is considered a misrepresentation of the medical necessity requirement for coverage of services. Identification of this type of documentation will lead to denial of services for lack of medical necessity and recoupment of all overpayments made.”

Noridian: Documentation Software Templates“NAS Part B MR has noted that some Electronic Medical Record (EMR) software programs auto-populate certain aspects of the medical record with information that is not patient specific. This issue is more profound in the HPI when discussing the context of a certain illness and/or co-morbidity. Documentation to support services rendered needs to be patient specific and date of service specific. These auto-populated paragraphs provide useful information such as the etiology, standards of practice, and general goals of a particular diagnosis. However, they are generalizations and do not support medically necessary information that correlates to the management of the particular patient. Part B MR is seeing the same auto-populated paragraphs in the HPI’s of different patients. Credit cannot be granted for information that is not patient specific and date of service specific."