A 2017 study of over 23,000 patient progress notes for one particular software showed that only 15% of the text was entered manually. The rest was either cut and pasted or “imported”. The hospital system has since changed its policy on the use of cut and pasted text. Some have said this is Clinical Plagiarism when information is copied from another chart. Payers have warned providers about documentation and the lack of original information in the record. Note Bloat is a new term that comes from the large amount of superfluous information that is being placed in patient’s records.
What is your provider’s documentation like? How much of it is unique information about today’s visit? How do you analyze charts to see if you have a problem with a lack of originality in notes about a patient?
The duplication of prior documentation is the start of the process. Whether information is cut and pasted, pulled forward, or entered with a smart phrase, compliance issues exist. What information IS ALLOWED to be incorporated in another day’s note will be discussed. What is allowed from a compliance perspective? Looking at one patient note may not give a reviewer the insight they need about the patient’s record and their provider’s habits with documentation. What does your medical record software ALLOW providers to do? Finding and analyzing this information as well as what different payers have said about Cut and Paste and Clinical Plagiarism leads to a better understanding of the issues. This will help listeners to form a plan for analysis of their records and come up with an action plan in working with their providers.
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