When I speak to professional organizations on the topic of clinical documentation, I like to show a slide of Larry Tesler, and ask if anyone knows who he is. So far, no one has been able to identify him (at least, not unless they’ve been to one of my talks before!). Mr. Tesler worked at Xerox’s Palo Alto Research Center (“PARC”) between 1973 and 1980 where, among other things, he worked on a word processing system called Gypsy. This was the first known application to incorporate “copy-and-paste” functionality. The term was a variation of “cut-and-paste” which was a traditional practice in editing manuscripts, where sentences and paragraphs were literally cut from a printed page with a scissors and physically pasted onto another page. In 1983, the Apple Lisa (predecessor to the popular Macintosh computer) commercialized the use of copy-and-paste, and was the first text editing system to name a “clipboard” as the intermediate storage that made copy-and-paste work.
At the very mention of the term “copy-and-paste”, attendees at my talks can reliably be expected to let out a collective groan (and the occasional hiss or “thumbs down” hand gesture). After all, copy-and-paste certainly has a deservedly bad reputation for being used carelessly in the creation of clinical documentation. But the point of this discussion is not to discuss the problems of using copy-and-paste, rather, to discuss its potential virtues.
Everyone involved in preparing for the transition to ICD-10 is well aware of the need for increased specificity in clinical documentation. This is especially true when looking at the documentation requirements for bone fractures. Where better to find the detailed description of a fracture than in the radiologist’s report? Since coding cannot be based on information provided by someone not directly involved in the care of the patient (in this case, the radiologist), a strategy is needed to bring the detailed information from the report into a clinical note that is codeable. Enter copy-and-paste.
Here’s an example of how this can work. An orthopedic surgeon (for example) is consulted on a patient who fell and injured their hip. Towards the end of the consultation note would be language like this:
X-rays of the hip personally reviewed and discussed with the radiologist, Dr. Smith. His report of April 21, 2015 at 8:44 AM states:
[text of the note copied and pasted here]
I agree with his description of the location and nature of the fracture, and confirm that this correlates with the clinical findings described in my note (above).
While there are no definitive rules for what makes a reference to another’s work codeable in the chart, this note has several important elements, including reference to the orthopod’s direct involvement in the assessment of the x-ray and its interpretation, proper attribution to the author of the radiology report, and the linking of the radiographic findings to the clinical findings.
A similar approach should be considered for anatomic pathology reports. A note that says “Results of the bronchial biopsy are positive; will refer for outpatient oncology evaluation” is pretty useless to a coder (and to other care providers, for that matter). This would be the ideal place to copy-and-paste the findings from the anatomic pathology report. Perhaps this might also stimulate physicians to indeed review the pathology specimens with their colleagues, and not simply rely on reading a report.
While many hospitals have been diligent about providing cautions and policies with regard to restricting or regulating the use of copy-and-paste, I have yet to see a positive and constructive set of guidelines that say how it can and should be used. Perhaps readers of today’s humble blog entry can use this as a stimulus to start the discussion at your institution. Let me know what you come up with!
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