For the Week of December 5, 2016

In regard to medical records, what does the phrase “cloning” mean?

Copying and pasting documentation from a previous visit into the current visit of a medical record is known as “cloning.” In some systems some information is automatically populated from the previous visit information. Providers who do not validate the information that is brought forward and/or just accept the information can cause tremendous headaches from several different standpoints. Information that is not relevant to that patient visit and/or is inaccurate may be used to code and bill inappropriate charges. Inaccurate or incomplete information may pose a legal issue when someone is called upon to testify about the medical record documentation in a legal proceeding.