The act of “copy and paste” or pulling forward the information from past hospital visits can save time but can 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 this has only recently come to the attention of the payers.

Health information management (HIM) professionals should watch for this electronic health record (EHR) documentation bad habit, as it 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 the systems generally lead to overall poor documentation or promote fraud. Also highlighted is a recent finding stating EHRs are the key to controlling fraud costs because of audit trail capacities and related features.

Read the complete article in the June issue of the Journal of AHIMA or online at journal.ahima.org .