Doctor Admits to Copy and Paste in EHR Records and May Face Accusations of Fraud

A Veterans Health Administration pulmonologist admitted to the copy-and-paste of prior information entered by other providers into the assessment of over 1200 patients.   Prosecutors are saying this may amount to falsification of a government document.

The article is available here.

This would appear to be a grey zone unless the information was inaccurate or was inflated and led to billing levels that were not supported by medical necessity.  The method by which information that is entered into the record, weather it be typed in directly by the provider, a medical assistant, scribe, transcriptionist, through copy-and-paste or through templates is not what is generally treated as important.  The provider who signs off on the record is validating that its content is accurate and any associated E/M billing level is supported by both accurate documentation and medical necessity.

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