Jun 24, 2025
Written By Elizabeth Cifers
In the high-demand environment of retina clinics, efficiency is a necessity. Physicians and staff are under constant pressure to move quickly, care for more patients, and adhere to the schedule. With this in mind, it’s no surprise that many physicians turn to time-saving tools, such as templated documentation and copy-paste features, built into electronic health record (EHR) systems. These tools can streamline workflows and reduce administrative burdens; however, they also carry significant risks that are often overlooked.
Cloned notes are clinical entries that are copied from a prior visit without meaningful updates or changes. In retina care, where many patients have chronic, stable conditions, this practice can seem like a logical time-saver. However, even small oversights can have significant consequences when documentation doesn’t accurately reflect what happened during the visit.
The risks of cloned documentation have been stressed by the U.S. Department of Health and Human Services Office of Inspector General (HHS OIG) in two major reports. In its 2014 review, the OIG reported that many did not implement basic safeguards in their EHR systems to detect or prevent the fraudulent use of copy-paste functions. The report warned that when physicians replicate clinical documentation without making appropriate updates, it can result in “inaccurate, fraudulent, or unwarranted documentation” that may lead to inappropriate billing and compromised care (OIG, 2014).
The 2020 follow-up report delved deeper, focusing specifically on the copy-paste functionality across multiple healthcare organizations. The OIG found that copied progress notes were often not reviewed or edited to reflect the current visit, which can be misleading and pose risks to patient safety. Alarmingly, some EHR systems lacked features to clearly identify when content had been copied, making it difficult for auditors and internal reviewers to assess the integrity of the documentation (OIG, 2020).
For retina practices, this means that using cloned notes without thoughtful review and customization can place physicians at risk for compliance violations, billing errors, and even allegations of fraud.
Payers and auditors closely examine clinical documentation for signs of authenticity. Identical notes across multiple visits, especially when accompanied by high-level billing codes and modifiers, can signal potential abuse. If a physician’s documentation doesn’t accurately support the services rendered, the result may include denied claims, repayment demands, penalties, or more extensive legal scrutiny.
Even well-intentioned use of templates or copied content can create problems if it appears that the physician did not actually perform or reassess the elements documented in the note. Retina practices must ensure that each note accurately reflects a unique and current patient encounter.
Efficiency in documentation is important, but it must not come at the cost of integrity. Templates and EHR shortcuts can be valuable tools, but only when used as starting points, not as final documentation. Each note should be personalized with updated exam findings, changes in medical history or symptoms, and thorough documentation of treatment decisions and plans. ‘Thorough’ doesn’t mean the documentation is verbose, but it does mean it is supportive.
Even brief additions to the exam, such as “VA improved OS” and “VH improved OS,” and other similar information, help demonstrate that the physician conducted an evaluation and made decisions based on current findings.
To protect against the risks of cloned notes, retina practices should foster a culture of accurate and thorough charting. This begins with educating physicians, scribes, and clinical staff on the importance of avoiding verbatim note duplication and the potential regulatory consequences that can result from it.
Regular internal audits can help identify problematic patterns and provide practices with an opportunity to make corrections before issues arise during external reviews. EHR vendors should also be encouraged to implement features that flag copied content and require physicians to verify changes.
Cloned notes may seem like a harmless shortcut, especially in a fast-paced retina practice. However, as both HHS OIG reports make clear, this approach to documentation carries significant risks, ranging from billing denials to compromised patient safety. By remaining vigilant, personalizing each patient encounter, and fostering a culture of compliance, retina physicians can safeguard their practice and ensure that their documentation supports both quality care and audit readiness.
Are you seeking a partner to assist with implementing compliance activities at your retina practice or group? Elizabeth Cifers is certified in Healthcare Compliance and has decades of experience in one of the most significant risk areas for noncompliance: medical coding and billing. She offers consulting, risk assessments, chart audits, training, and more. Book a free 30-minute consultation with Elizabeth here.
U.S. Department of Health and Human Services, Office of Inspector General. (2014). Not All Recommended Fraud Safeguards Have Been Implemented in Hospital EHR Technology (OEI-01-11-00570). https://oig.hhs.gov/oei/reports/oei-01-11-00570.pdf
U.S. Department of Health and Human Services, Office of Inspector General. (2020). Copy-Paste Documentation in Electronic Health Records (OEI-01-18-00330). https://oig.hhs.gov/oei/reports/oei-01-18-00330.pdf
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