In the April issue of The Rheumatologist (p. 17), our ACR coding experts referred to this practice as “cloning,” which is defined as the cutting and pasting of the note from one visit to another. As described in the article, if a history of present illness (HPI) note is carried over from a previous visit, but the chief complaint and present illness do not match the review of systems (ROS) that the patient filled out, the note is not considered to be pertinent to the current visit, raising a red flag for our friends at the Office of the Inspector General (OIG) of Medicare. Can you spell “audit”?
Yet, cloning is not the only adverse behavior seen with the burgeoning use of electronic records. Composing redundant notes devoid of any clinical curiosity, critical thinking, or thoughtful review may be legal, but they are equally harmful to patient care. In a recent study, researchers from Columbia University in New York City actually attempted to quantify the redundancy of the clinical narrative in the EMR. They found that the signout and progress notes proved to be particularly redundant; the former contained an average of 78% and the latter 54% of information duplicated from previous documents. There was also significant information copying between document types (e.g., from an admission note to a progress note). The result is the creation of medical records that are bursting with kilobytes of irrelevant data and replete with copious notes that may inadvertently hide the clinical clues and critical observations that we are searching for.
Another development that has threatened the quality of the medical narrative has been the use of templates in the EMR. Though they allow for the concise and complete entry of important data that may otherwise be overlooked or forgotten, templates tend to crowd out space for the entry of free-form text and thoughtful observations. To many note writers, the use and abuse of templates appears to be a modern day issue, but the tension between using a formulaic approach to documentation versus a narrative one is not new. A wonderful review of the history of the medical record, written by Eugenia Siegler, MD, professor of clinical medicine at Weill Cornell Medical College in New York City, noted that concerns about the variable quality of physician documentation have been a recurrent theme in the medical literature for nearly a century. She describes the evolution of the medical record as it occurred over two centuries at the New York Hospital (NYH).