A note can be copied in two ways from within a patient's record:
- Make a duplicate of an existing note when using the same note type.
- Use the SALT (Same As Last Time) feature to copy sections of a previous note into a new one, regardless of note type. If the new note type is different than the one being copied, only sections that are common in both notes will be copied.
| || |
Copy an Existing Note Using the Same Note Type
| || |
Open a new note and use the SALT feature to copy a previous note. If the new and previous note types are different, only sections that are common to both will be copied. Sections from the original note that do not appear in the new note will not be copied over.
Note: If you are using SALT to copy information into a different note type, it is recommended to double check the copied sections to avoid any loss of information between the notes.
Important: An OIG report calls out the risk of inaccuracy when using copy/paste, or cloning, of a previous note in EHRs. CMS plans to issue guidelines regarding the appropriate use of a copy/paste feature in EHRs. In anticipation of these guidelines, Kareo has implemented OIG's general recommendation by adding the log file entries pertaining to the copying of a note (author of the note, identifying the note as a copied note, and referencing the original source note). These log file entries are not visible within Kareo, however, a practice can request a copy of the log entries related to this feature through Kareo support. Once CMS publicly releases the guidelines, Kareo will implement any changes necessary to ensure that Kareo users are in full compliance.
Note that using your computer's or your browser's copy/paste feature while using Kareo is not captured in the log files.
Kareo recommends the following best practices to ensure a practice can pass an audit regarding copy/paste of a note:
- Confirm that the copied note is an accurate documentation of the latest patient encounter and update any items that may no longer apply.
- Validate that the Evaluation and Management (E&M) code submitted is fully supported by the newly copied and edited note.
- Validate the diagnosis codes submitted with the claim; do not automatically utilize the same codes from the source note. Auditors monitor claims for recurring diagnosis codes for what is typically a “short-term” condition (flu, cold, rash, etc.). However, if the patient is still under treatment for this condition, do not hesitate to report the appropriate codes.
- Validate that any other procedure code(s) submitted was actually performed in the new encounter and not a result of the copied note.