Page 18 - Part Two Risk Reduction Series - Documentation

SVMIC Risk Reduction Series: Documentation

Pitfall #2 – The Use of “Copy & Paste”

The second pitfall is using copy and paste capabilities to create

the most recent office note by using a previously-documented

assessment. While there are appropriate clinical reasons for a
practitioner to review the notes from the patient’s last office visit to

determine whether or not symptoms have resolved or worsened,

the use of a “copy and paste” capability to create the new note

from the old one is fraught with potential for inaccuracy in

documentation.

“Copying” information from a prior note and “pasting” it into a new

note may result in notes which are identical for multiple office

visits. This is particularly risky for the physical examination, which

may have changed since the prior patient encounter and now may

not reflect the complexity of changes in the patient’s condition. It
may result in irrelevant over-documentation, perpetuate outdated

or incorrect information and produce voluminous progress notes

that obscure important new information.

In litigation, repetition of identical notes, including the errors in

those notes, will raise questions about whether or not the
physician reviewed the note for accuracy. When the accuracy of

the medical record is questioned, the trustworthiness of any

portion of the record is then also questioned. Ultimately, the

plaintiff’s attorney will raise questions about whether or not the

physician’s lack of attention to the medical record documentation
also reflects a lack of attention to the patient’s care.

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