The health IT community is well aware of the dangers of cloning notes in an electronic medical record. I include myself in that group. Until recently I prided myself for doing a good job, both in our EMR design and in my own personal practice, of using just the right amount of automation in our documentation workflow. Two recent events showed me that I still have some work to do.
The first event occurred a few weeks ago when I was reviewing some records. One patient note documented an enlarged salivary gland containing a stone. That would be fine except for one small detail – I had removed that gland one week prior to the date of the note! My nurse had created that note. A conversation with her revealed she thought she was doing the right thing by always clicking the “previous finding” button, which I had programmed myself. My nurse is extremely bright; this was my fault for not training her on this issue. I had also signed that note. So it was my fault twice. After a 30 second conversation with my nurse it has not happened since.
The second event was when an attorney interviewed me regarding one of my patients. I was a treating physician in a malpractice case (I am not the defendant thankfully). The attorney wanted to know if, in my opinion, the physician defendant had met the standard of care in treating the patient despite the adverse outcome.
This was a high-risk case for note cloning; the patient had multiple abnormal neurologic findings that were stable over time. In reviewing my records I was satisfied that my notes were accurate, complete and original for every visit. I avoided cloning those abnormal but stable findings by describing the same exam but using slightly different wording at each visit. How else do you avoid cloning? But the attorney pounced on my small changes in description, trying to establish a trend in my notes that the patient was getting worse. I explained the cloning issue to him, and he understood…. I think. Nonetheless I felt somewhat uncomfortable defending my documentation, and I was not even the defendant. In trying to avoid cloning notes I had stepped right into another problem.
This issue is huge in my practice. I have a large volume of head and neck cancer patients. The essence of caring for them properly is to monitor them for changes in their abnormal – but stable – physical findings. A recurrence of cancer might manifest as a subtle change in one of these findings.
How do you document that an examination is stable and unchanging, but change your wording enough to document that you actually examined the patient at every visit? We do not yet have the cloning issue figured out.