Documentation – A Provider’s Responsibility For Originality

Electronic medical records revolutionized medical records.  As of 2021, 88% of physician offices had some form of computerized health records for their patients.  The astounding 50% increase in numbers 2008 statistics, was not without growing pains and compliance issues.  First cut and paste issues were identified with physicians not doing the work of documenting the services they performed.  There were early warnings to hospitals from CMS about this practice, but physicians did and still use and re-use information from chart documentation into the same chart and into other patient’s charting creating compliance issues.  Clinical plagiarism was the next identified issue with providers copying information from another provider and pasting that information into the patient’s chart.  The information was not identified as being from someone else, hence the name clinical plagiarism.