Preparing for a chart audit
Understanding why audits happen, and preparing for a potential audit of your client records, can help you set your best foot forward.
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Compliance and documentation
Understanding the risks of EHR cloning in therapeutic settings
EMR cloning may initially seem like a time-saving technique, but it poses serious risks.
Electronic Medical Record (EMR) cloning refers to the practice of duplicating and pasting previous medical entries into new records without adequate personalization. This might involve copying whole sections of patient history, examination results, or treatment plans from one patient encounter to another.
Why is EMR cloning a problem?
EMR cloning may initially seem like a time-saving technique, but it poses serious risks:
- Accuracy and relevance: Cloned entries may not accurately reflect a patient's current condition, leading to treatment based on outdated or incorrect information.
- Potential for errors: Inaccurate medical records can result in improper treatment plans, potentially endangering patient health.
- Ethical concerns: The integrity of medical documentation is compromised, questioning the professional ethics of healthcare providers.
HIPAA violations: Copying and pasting sensitive information could potentially violate HIPAA.
Consequences of EMR cloning in audits
During an audit, the discovery of cloned notes can have severe implications:
- Legal repercussions: Providers may face charges of fraud, leading to legal battles or sanctions.
- Reputational damage: Clinics and professionals may suffer damage to their credibility, which can be difficult to recover from.
- Financial penalties: Significant fines or loss of reimbursement from insurance entities could ensue, impacting the financial stability of healthcare practices.
How to identify EMR cloning
To illustrate what EMR cloning looks like, consider the following example.
The original entry contains this note:
"Patient reports increased anxiety, difficulty sleeping, and occasional headaches."
The cloned entry contains this note in a subsequent visit, without mention of any assessment of changes or updates based on the last visit:
"Patient reports increased anxiety, difficulty sleeping, and occasional headaches."
To avoid cloning, you should note a shift in the symptoms or provide an update from what was previously stated. A better version of this entry would be:
"Patient reports continued increased anxiety and difficulty sleeping, but denies ongoing headaches, attributing this to successfully reducing screen time.”
It’s imperative to avoid EMR cloning to prioritize your patient’s health, as well as to avoid severe provider consequences.
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Compliance and documentation
Preparing for a chart audit
WHO-5 wellbeing assessment
Learn more about the World Health Organization-Five Well-Being Index and how you can use it in your practice.
Using measurement-based care in therapy
Administering assessments to diagnose and treat a client’s evolving symptoms can provide a picture of how your client is doing over time.