Clinical Plagiarism - Is Your Documentation Putting Your Practice at Risk?-246223

Video Transcription

Video Summary

Jill Young's presentation addresses the intricacies of medical documentation, emphasizing the risks associated with improper practices like cutting and pasting, using templates, and cloning within electronic health records (EHR). These practices pose risks during audits and can lead to accusations of fraud or improper billing, as they often result in records that do not accurately reflect the patient's current state or medical necessity. <br /><br />Young highlights the importance of documenting original work exclusive to each patient encounter, aligning with Medicare standards that determine payment based on medical necessity, not the volume of documentation. The shift in guidelines, particularly for office, outpatient, and upcoming 2023 changes for hospital and observation services, reduces emphasis on extensive history or physical exams. Instead, accurate medical decision making or time serves as the criteria for billing, simplifying the documentation process and discouraging extensive, templated records.<br /><br />Young advises against reliance on EHR features that facilitate cloning and copying, urging practitioners to instead use brief, original narratives that genuinely reflect the patient's current condition and treatment plan, ensuring compliance and potentially reducing unnecessary workload.

Keywords

medical documentation

electronic health records

improper billing

fraud prevention

Medicare standards

medical necessity

documentation guidelines

original narratives

compliance