Why and How To Avoid Note Cloning as a Therapist

Before diving into the best practices on how to avoid note cloning, it’s important to first and foremost 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 is the malpractice of copying and pasting the medical information without providing unique, original content to that individual and the encounter you’ve had with them. Each unique encounter requires that you update the data related to the client and event. 

For example, it’s considered a cloned note if every entry in a patient’s record is either worded exactly the same or contains too many strong similarities. 

This issue is particularly problematic for medical and mental health professionals who are using electronic health records (EHRs) with standardized forms or formats.

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 healthcare documentation is when medical information is copied directly from another source without being updated, thereby not accurately   capturing a patient’s condition.
2. Copying Therapy Notes and Pasting Without Updating the Content Copying and pasting is when a healthcare professional selects data from a previous source (which in this case is considered the original version) and reproduces it at 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 Similar to copying and pasting, cutting and pasting is when someone removes or deletes the original data to transfer it to another source. This method should be avoided  as it can alter the information of the notes on the original source material.
4. Copy Forwarding and Deleting Destroying Documents Copy forwarding occurs when a user copies past documentation to a new  location without needing to retype it. In other words, users can reuse the same information from the previous months to “update” the current months without needing to input anything into the system. This is a function that is 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. However, it also opens doors to over relying on predefined texts to document a patient’s visit. Without adding original content to the template, healthcare providers can miss out on crucial information that a therapist may need to further access and treat a clients presenting problems and diagnosis.
6. Copying Therapy Notes by Populating by Default Some EHR  systems also offer features that populate (or fill in) a spreadsheet automatically based on previous activities. In this case, the author doesn’t need to take specific action to input data, which can increase the number of errors in the notes and can be mistaken for note cloning.

What's Wrong with Copying Notes in EHR?

The shift from paper to electronic medical records introduced incredible conveniences. But it also gave rise to unforeseen ethical challenges  — one of which is cloning.

In the field of medicine and psychology, providing the necessary care constitutes one, albeit highly important, portion of the job. Accurate documentation serves as the other necessity. Both of these components work hand-in-hand to ensure that patients receive the treatment that they are seeking. 

CMS (Medicare) once said in late 2015 that cloning has become a problem in healthcare that’s not broadly addressed. They expounded by saying that copying records can indicate fraud. It can also invite unnecessary inquiries and audits, create stress and place a strain on already scarce resources. 

To provide the necessary care, these documents need to demonstrate  differentiating factors  and unique characteristics that separate one person from the other. 

The problem here is that when mental health and medical professionals  clone information, they risk overlooking   nuances in the interaction between the treatment provider  and the person seeking treatment. 

In short, improper documentation can compromise client care. 

What the Research Shows on Therapy Progress Note Cloning

The primary goal of progress notes is to provide the healthcare professional with a concise and updated reflection of their patient’s current condition. However, copying or importing these texts from another source increases the risk of incorporating outdated, unnecessary, and inaccurate information, which can then lead to clinical error and improper treatments.

According to a recent study found in the Journal of the American Medical Association, researchers discovered that among over 23,000 progress notes written by 460 clinicians, only 18% of these were newly entered. 46% of the notes were copied and 36% were imported. 

To minimize cloning in EHR, some companies offer their staff an array of tools to assist them with their documentation, such as auto-generated text and speech recognition. 

Despite these added features, many electronic health records providers still make extraneous and unnecessary data documentation. For this reason, reputable medical and progress note assistance programs offer specific guidelines to streamline electronic medical record documentation and encourage clinicians to create  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 simple ways to go about it. While a more dedicated approach is to stay proactive and write your patient’s notes manually, there are other creative, ethical best practices to consider. 

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 electronic health records is that it boosts efficiency and productivity. It has several features that allow you to streamline processes to accomplish administrative tasks faster. 

That said, if you want to make the most of its features while avoiding cloning information, you need to familiarize yourself with CMS guidelines for locking charts. These 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 information that must never be copied includes signature blocks, patient charts, medical history, and progress notes.
• While there may be similarities between different patients' presentation and treatment, the creator of the note needs to review each note to avoid copying them verbatim.
• Templates and structured notes are allowed, but they should be filled manually with at least some original content each time.
• Authors need to review the note’s accuracy, relevance, and completeness before locking notes.
   

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, you may need  certain features that are present in one EHR and not in another. 

Therefore, it’s imperative to do your research, consult with colleagues, and find software options that fit the majority of your objectives. 

No one EHR platform is personal, but implementing the best system can help you run your practice smoothly and make it easier for you to manage your daily tasks, including writing patient notes. 

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

• Pinpoint a select list of comprehensive mental health EHR systems available
• Enumerate 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
   

We at the Clarity Cooperative offer a comprehensive guide to help you select the best EHR system to meet your needs and document client information properly. 

Exercise Caution: Avoiding the Risks of Note Cloning

As a therapist with much on your plate, it’s easy to get caught up in overlying on  the most convenient features the system offers. That’s why it’s important for you to always be mindful of best practices when using them. Before locking any documentation, thoughtfully review your notes and see if the details you’ve included are accurate to each unique patient. 

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

If you need further assistance in terms of notetaking, be sure to explore Clarity Cooperative’s Progress Note Generator, which we’ve lovingly called “Clarity Notes”. 

It’s a robust point-and-click program with pre-set phrases to help you create customized, confidential, and comprehensive progress notes on your patients. 

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

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 in mind, you can minimize the likelihood of making cloning mistakes and ensure that you’re providing the best care for your patients. 

Should you need guidance and support in navigating your practice, the Cooperative is here to 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 that 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,