Page 17 - Risk Reduction Series - Documentation Essentials (Part Two)

SVMIC Risk Reduction Series: Documentation Essentials

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perpetuate outdated or incorrect information, and produce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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