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:
- Don’t copy and paste repeatedly something that has been previously copied and pasted. Don’t copy and paste previous interval histories sequentially, day after day.
- Don’t copy and paste inaccurate information. I have seen a provider import the results of a study which was done in a prior encounter, and then it gets propagated as if the results were in a current study. I have seen a reference to “POD #2” when the procedure was historical. I have seen DVT prophylaxis referenced day after day, when it had not been initiated. If you copy and paste a spelling or grammatical error, the government knows it is not novel documentation today.
- If you copy and paste documentation which has temporal references in it, either remove them, edit them, or choose not to C&P. Was 20 mg Lasix given three days in a row for a total of 60 mg, or only on the first day and then copy and pasted for the next three days? Was Dr. Green spoken with today and yesterday, or just yesterday and there was careless C&P?
- Don’t C&P someone else’s work product without attribution. There is an audit trail and it can always be discovered as to whose original documentation it is. I saw a surgical consultant copy and paste the entire H&P from the admitting physician, including, “Consult ME.” This is not lazy documentation; this practice is called FRAUD.
- Don’t copy and paste excessive, extraneous information. CMS does not reward volume of documentation. Note bloat makes it harder to care for a patient. You do not need to import the entire radiology report, including the amount of contrast or the radiologist’s signature line. You do not need to import the same radiology study impression three days in a row. Don’t bring in microbiology results from a non-existent wound that healed six months ago.
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.
