If you’ve worked with electronic health/medical records (EHRs or EMRs) even a little bit, then chances are that you’ve heard about all the dangers associated with cloned notes. In short, cloned notes are pieces of patient information that the program automatically pulls from previous documentation. This leads to many records being inaccurate, as the provider simply uses the patient info that was already stored on the system without checking or updating it.

Unsurprisingly, the danger of cloned notes has been a hot issue, as it saves the provider precious time but runs the high risk of using outdated info that could have come from anyone who had access to the patient’s record. In response, many EHR systems introduced the concept of tagging, which uses the same method of copying information only with the original author tagged, similar to a footnote in a research paper. While this may improve the situation somewhat, the new issue becomes providers tagging documentation from other physicians and using it either to shortcut the documentation process or to change a plan of treatment entirely.

In fact, tagging may present even more danger, as the reference to another medical professional can make it even easier to take the information at face value. If Dr. A is running short on time and sees that Dr. B has previously uploaded the patient’s basic info, he could simply tag Dr. B without ever confirming whether or not the info had changed, and the record would still have a physician’s name directly attached. Worse still, it opens the possibility of intentionally defrauding insurance companies by tagging information that doesn’t even pertain to the most recent encounter in the first place.

Because of all the potential risks, coders should be careful to review all documentation thoroughly, even if it has been signed off on by one or more providers. If you find anything that doesn’t seem to match up, contact your provider or practice manager immediately.