Effective Date: 10/01/2016
Responsible Department: Medical Services
Revised Date: 06/23/2022
Reviewed Date: 06/23/2022
Introduction
In 2009, the United States government implemented the transition to electronic health record (EHR) technology. While EHR tools offer many invaluable benefits, certain features may compromise the integrity of the medical documentation if not used appropriately. Workforce Safety & Insurance (WSI) considers any record containing non-authentic documentation a falsified medical record. The purpose of this document is to outline WSI’s policy on falsified medical records.
Definitions
Cloning – The practice of using previously documented information to document a current patient encounter, e.g., carry-forward, copy/paste.
Non-Authentic Documentation – The result of using cloning in the medical record. Features like auto-fill and auto-prompts can result in cloned medical records. This can occur in documentation between visits for a specific patient or in documentation from patient to patient.
Policy
WSI considers any record containing non-authentic documentation a falsified medical record. Each entry in the record must have identifiable and appropriate updates specific to the individual encounter. WSI will audit all medical documentation for medical appropriateness, necessity, and authenticity. It is the expectation all documentation in the medical record must:
- Be specific to the patient
- Be specific to the encounter
- Accurately reflect the services performed
- Support the necessity for the services
- Clearly identify who performed the services and assessments documented
- Clearly identify the author of each note or entry
- Clearly identify the date and time of the entry
In the event a medical audit reveals falsified information, WSI will only reimburse the level of service supported by authentic documentation.
References
American Health Information Management Association. (2012, January). Information integrity in the electronic health record. AHIMA. Retrieved June 19, 2025 from https://www.ahima.org/media/sxflfny0/information-integrity-in-the-electronic-health-record_axs.pdf
U.S. Government Publishing Office. (2009, February 17). American Recovery and Reinvestment Act. Pub. L. No. 111-5, 123 Stat. 115. Retrieved November 2, 2020, from https://www.govinfo.gov/content/pkg/PLAW-111publ5/pdf/PLAW-111publ5.pdf