In review of a clinic record, a CDI specialist notes the provider has directly copied and pasted a previous inpatient problem list into the current…

The best course of action is to address the root cause of the documentation issue. Copying and pasting a problem list without validating each diagnosis for the current encounter can lead to inaccurate records, coding errors, and patient safety risks. Educating the provider on the proper use of the EHR, the importance of encounter-specific assessments, and the risks of "note bloat" is a core function of a CDI specialist. This proactive approach improves the quality of documentation for all future encounters, rather than just correcting a single record.

A. Do not code conditions that were pasted from the problem list.

This is a reactive coding decision, not a proactive CDI intervention to improve the documentation itself.

B. Query the provider for each of the conditions on the problem list.

This is inefficient and may cause provider abrasion; education is a more effective, systemic solution.

D. Assume the conditions are all relevant for this visit.

This is a dangerous assumption that compromises data integrity and patient safety, as not all past problems are currently active or managed.

1. American Health Information Management Association (AHIMA). (2013). Integrity of the Healthcare Record: Best Practices for EHR Documentation. Journal of AHIMA, 84(8), 58-62. This practice brief discusses the risks of copy-and-paste functionality (Section: "Appropriate Use of Copy and Paste") and emphasizes the need for organizational policies and provider education.

2. ACDIS. (2022). CCDS-O Certification Study Guide (3rd ed.). HCPro. Chapter 2, "The Role of the Outpatient CDI Specialist," emphasizes provider education as a key responsibility for improving documentation quality and addressing problematic practices like inappropriate copy-paste.