Why and How To Avoid Note Cloning as a Therapist

Have you heard of the term "note cloning?" 

We're going to be diving into the best practices on how to avoid note cloning. But, first it’s important to understand what “note cloning” is. 

If you’ve ever heard of this concept, you might be wondering, what exactly is a cloned note? 

Essentially, note cloning copying and pasting the medical information. Note cloning is a malpractice. These copied notes don't give unique or original content to each encounter with a client. Each time you meet with a client, its required to update the data so that it is relevant to the event. 

A note is considered cloned if every entry in a client's record is exactly the same, or is too similar. 

What Is Therapy Progress Note Cloning in Electronic Health Records (EHR)?

There are different ways clinicians can clone patient records. These include the following methods: 

1. Copying Notes from Other Clients 
   Cloning in healthcare is when medical information is copied pasted from another chart. There should be updates made to this. When it's copied like this, it doesn't paint an accurate picture of the client's condition.
2. Copying Therapy Notes and Pasting Without Updating the Content 
   Copying and pasting is when you choose data from the original source and reproduce it in another location. You may ask “Is copy and paste an acceptable form of patient care documentation?” The answer is no, it’s not.
3. Cutting and Pasting 
   This is similar to copying and pasting. Cutting and pasting is when you remove the original data to transfer it somewhere else. It's best to avoid this because it can alter the information in the original note.
4. Copy Forwarding and Deleting Destroying Documents 
   Copy forwarding is when past documentation is copied to a new location. You can reuse the same information from previous notes to "update" the current ones. You wouldn't put anything new into the system. This is a function that is often available in EHR systems.
5. Using a Template and Not Adding Original Content 
   Using a template is helpful to cut down the time it takes to do administrative work like filling out forms. It also opens doors to over relying on predefined texts to document a client's visit. If there isn't any original content added to the template, there could be important information missing. Therapists need access to this data to treat a client's presenting problem, or to accurately diagnose.
6. Copying Therapy Notes by Populating by Default 
   Some EHR systems also offer a feature that autopopulates certain fields. They take information from previous notes. if you're doing this, you wouldn't need to type in anything on your own. This increases the chances of errors in the notes and could also be mistaken for note cloning.

What's Wrong with Copying Notes in EHR?

When the industry shifted from paper to electronic records, it brought streamlined conveniences. It also gave rise to some unforeseen ethical challenges, though. A big one is note cloning. 

The field of psychotherapy comes with providing necessary care. Thats one part of the job. The other is accurate documentation. It's an absolute necessity. These two parts work hand-in-hand to make sure the patient is receiving high quality treatment. 

CMS (Medicare) said in late 2015 that cloning has become a problem in healthcare. They also said that’s not been widely addressed and that copying records can look like fraud. If there's any chance of fraud, it brings inquiries and audits. These situations can cause stress and strain on already scarce resources.

Each document needs to show unique characteristics that separate one person from another. The problem with therapists that clone information is that they can overlook subtle nuances. Cloning makes each note generic and doesn't include all the information to provide necessary care. 

In short, improper documentation can compromise client care. 

What the Research Shows on Therapy Progress Note Cloning

Progress notes give you a concise and updated reflection of the client's condition. However, when they're copied or imported from other places, it might not be so concise. There's a chance that you're including outdated and unnecessary information. It might even be inaccurate. This can lead to clinical errors and as a result improper treatment methods. 

A recent study in the Journal of the American Medical Association surveyed 460 therapists. They found that among 23,000 progress notes, only 18% were new. They found that 46% of the notes were copied and 36% were imported. 

Some companies have taken on tools to help minimize cloning. Some of these tools help therapist with documentation. Features include auto-generated text and speech recognition. 

Even with these features, a lot of therapists still include unnecessary documentation. Because of this, there are programs that help with writing progress notes. They give specific guidelines that help streamline documentation. It also helps clinicians write notes ethically. 

Best Practices Against Therapy Progress Note Cloning

Now the question is: how do you avoid making any of the above mistakes? 

Well, there are few ways to go about it. You can continue to write your client's notes manually. There are also creative methods to consider that are still ethical. 

Some of the best practices listed below can help you avoid note cloning.

Understand the CMS Requirements for Electronic Health Records

One of the benefits of EHRs is that it boosts efficiency and productivity. They have several features that allow you to streamline and get administrative tasks done faster. 

You'll need to familiarize yourself with CMS guidelines for locking charts. This way you can make the most of EHR features while avoiding cloning information. The guidelines include the following:

• It is appropriate to copy and paste when you’re transferring demographic information.
• Copied information must be selective, brief, and pertinent to the patient’s care during their visit.
• The following information should never be copied: signature blocks, patient charts, medical history, and progress notes.
• There may be similarities between different patients' in terms of presentation and treatment. The writer of the note needs to review each note to avoid copying them verbatim.
• Templates and structured notes are allowed. They should be filled manually with at least some original content each time.
• Review the note’s accuracy, relevance, and completeness before locking it.  
   

Find the Best EHR System That Works for You

Another best practice is to find the ideal EHR system that works for your specific practice. Depending on what you specialize in, one specific EHR might have features that you want. Not all EHR systems will be identical. 

This highlights the importance of doing your research. You can consult with colleagues to get tips on which software options might fit you. 

It's unlikely that one EHR platform is going to meet all of your specific needs. Still, you can use the best one that will help run your practice and make it easier for you to manage tasks.  

To help you get started on this process, here are considerations:

• Pinpoint a select list of comprehensive mental health EHR systems available
• Count the features that you need
• Compare systems with one another to see the clear advantages of each one
• Review the system architecture to determine whether it aligns with your work process
• Request a demo or start a free trial so that you can decide which system best suits you
• Read client reviews
• Consult with colleagues
• Tap their customer service to get any unanswered questions or concerns clarified 

The Clarity Cooperative offers a comprehensive guide that helps you select the best EHR system. You can look at our checklist to see which meets your needs. The right one will help you document client information properly. 

Exercise Caution: Avoiding the Risks of Note Cloning

As a therapist with so much on your plate, it’s easy to get caught up. The convenient features make it easy to over-rely on them. That’s why it’s important for you to always be mindful of best practices when using them. Before locking, review your notes and see if the details you’ve included are accurate and unique to each client. 

Explore the various Progress Note Generators at Clarity Cooperative - “Clarity Notes”

If you need more help with note taking, be sure to explore Clarity Cooperative’s Progress Note Generator. We lovingly call it “Clarity Notes”. 

It’s a robust point-and-click program with pre-set phrases. It helps you create customized, confidential, and comprehensive progress notes for every client. 

We also have guidelines on how to stay HIPAA-compliant and avoid note cloning. 

Note taking can indeed be tedious and time-consuming. But when you have helpful peer-reviewed tools, you can eliminate the common issues associated with note cloning  and focus on what really matters - creating space for yourself so that you can focus on being present with your clients.

As we always say, Clarity is kindness. 
 

Join the Cooperative

With these recommended practices, you can lower the likelihood of making cloning mistakes. You can ensure that you’re providing the best care for your clients. 

Should you need support in navigating your practice, the Cooperative is here for you. We can help guide you as you nurture and expand a successful private practice. 

From essential resources and DIY tutorials to how-to guides, our platform offers a wide array of information. We can help you stay updated and in-the-know with the latest developments in our field as you  confidently grow your business.

We hope this helps.

With Clarity,

LPJ