Guest post: Exploring the importance of best practices for EHRs

by Crystal Stalter, CDIP, CCS-P, CPC

What is a best practice? Who or what defines it? We hear it talked about all the time, but what does it really mean, and to whom does it apply?

In the HIM/CDI/coding world, best practices can stem from information issued by established sources such as AHIMA, ACDIS, AAPC, CMS, the ICD-10-CM/PCS Official Guidelines for Coding and Reporting, or even our own hospital or employer handbooks.

Remember the definition of a best practice: a procedure proven to produce optimal results that should be followed as often and fully as possible. We must follow these practices—there is too much at risk for us not to.

One of the hottest topics of discussion related to best practices is the copy-and-paste functionality of the EHR. With this technology now widespread in the industry, is it ever okay to copy something from a previous encounter into a new one? This is the subject of lively debate between physicians and coders, as it raises a question about the legitimacy of the information being recorded. 

For example, a physician copies and pastes a medication list from a patient’s previous visit into a new encounter for that patient. The provider most likely intends to update the list with any dosage changes, additions, or deletions, but what if the provider gets distracted or simply forgets to complete the update? Even though there’s no malicious intent behind this omission, it’s easy enough for it to happen.

The same holds true for a physical exam or a review of systems, especially in EHRs where free-text is used and not checkboxes or prompts. Copying and pasting also raises the question of whether the most accurate diagnosis is being recorded. If the information is identical from encounter to encounter, it becomes harder to demonstrate medical necessity to the insurance company responsible for paying the facility’s claims.

What, then, is the best practice when it comes to documentation? Should a physician ever copy and paste any information, even if it saves time? Although copying and pasting is common, it is not considered a best practice. There are many hospitals and institutions where doing so is banned, and many software and EHR programs either provide an alert when something is copied from another record or prohibit the function altogether. Physicians have their hands full on a day-by-day basis, but we can bring a regularly occurring problem with documentation to their attention while still respecting their schedules and time.

Editor’s note: This article is part of a three-part series on best practices across coding, HIM, CDI, and other departments. The full article was originally published on JustCoding. Stalter is the CDI manager for M*Modal in Pittsburgh. Contact her at crystal.stalter@mmodal.com. Advice given is general. Readers should consult professional counsel for specific legal, ethical, clinical, or coding questions. Opinions expressed are that of the author and do not represent HCPro or ACDIS.