The document discusses guidelines for using the "copy forward" function in electronic health records. It begins by stating that EHR content must be of high quality and integrity as it is used for patient care decisions, is a legal document, and is a business record. It then outlines documentation requirements for EHRs such as notes being concise and accurate while emphasizing assessment and plan. The document cautions against duplicating information that does not specifically impact the date of service as it risks the integrity of the medical record. Proper use of the "copy forward" function is important to ensure documentation supports medical necessity and the level of service billed for each patient encounter.

1. The Electronic Health Record & use of the
'copy forward' function
Dos and Don’ts of ‘copy forward’ Functionality in Electronic Health
Records
Presenter
John E. Steiner
Follow us :

2. Objectives
© 2011 Rising Tide 2
1. Review documentation requirements for the Electronic
Health Record (EHR)
2. Explain guidelines for the appropriate use of “copy
forward” in the EHR to ensure medical record integrity
3. Distinguish “copy forward” versus “refer to” functions of
the EHR
4. Risks of using “copy forward” and practices to avoid

3. Introduction
• Clinicians use the EHR to make decisions about patient
care
• The quality and integrity of EHR content is important
• The EHR is a legal document, it should be compliant
with applicable legal requirements or standards
• The EHR also is a business record
© 2011 Rising Tide 3

4. Our Patient Empowered Care (PEC)
Model
© 2011 Rising Tide 4

5. Objective 1: Review documentation
requirements for the Electronic Health
Record (EHR)
1. Notes should be concise, accurate, non-redundant, and easy to
read.
2. Progress notes accurately describe treatment for a specific date of
service.
3. Place emphasis on the “assessment and plan” portion of the
note with the most definitive diagnosis to communicate the clinical
reasoning behind the plan.
4. Each note should stand alone, support medical necessity, and
support the level billed.
5. It is risky to duplicate information that does not specifically impact a
date of service.
© 2011 Rising Tide 5

6. To see the complete presentation check the
below link:
http://www.audioeducator.com/medical-coding-billing/copy-forward-
functionality-dos-donts-11-20-2014.html