Indiscriminate copying and pasting is the enemy of accurate, complete, concise, and relevant documentation.
Does copy and paste make you as crazy as it does me?! I have been doing a lot of chart reviews lately, and the only saving grace is that this healthcare system has a mechanism to gray out copied text, so I can find novel documentation more easily.
I have discovered that many providers set up their daily progress note “template” to just bring forward yesterday’s documentation in preparation for today’s note. I often ponder whether this practice is really in the best interest of the patient, and even the provider. Contemplating the patient’s current situation is key to deriving the best plan of action. The Centers for Medicare & Medicaid Services (CMS) frowns on “cloned” documentation. Is copy and paste really the best practice?
When I get to the topic of risky documentation practices in my presentations to providers, I ask them to raise their hands as to who enjoys the convenience of copy and paste. A few brave souls admit to it. My follow-up question is, “Who here likes reading other people’s copy and paste?” The attendees commiserate because NO ONE likes reading other people’s copy and paste.
Why not? Because even if the complaints and physical exam are exactly the same as yesterday, and even if the assessment and plan has not varied from yesterday, the reader can’t be certain that it is accurate today, or whether it was just hastily carried into today’s documentation without edit. It makes it extremely difficult to find the wheat amongst the chaff.
My personal opinion is that it is easier to spend a few moments thinking about what is critical to document today, and just compose that note, than to copy and paste the previous day’s note (or bring in a templated daily note) and have to determine what changes are necessary to make it tell the story accurately. I believe reordering diagnoses according to current severity or import is desirable.
However, if a provider’s practice is to copy forward yesterday’s note as a starting point, and he or she substantially and effectively edits the note so as to render it identifiably unique, I would not forbid it.
Here are my recommendations:
It may take a little less time and effort to mindfully edit copy and paste than it does to just create a new note; I’m not even sure that is true – I think it would take me more time. However, it may be in the patient’s best interest for the provider to consider the existing situation, to determine what is relevant and current, and then document it with a fresh perspective. It certainly takes less time than disputing a denial on the back end.
Indiscriminate copying and pasting is the enemy of accurate, complete, concise, and relevant documentation.
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