Physicians spend over 125 million hours in patient documentation outside of office hours.
(Gaffney et al., Medical Documentation Burden Among US Office-Based Physicians)
In physical therapy documentation, providers often face a dilemma: compromise patient care quality or create poor clinical documentation. Ideally, physical therapists would secure both care quality and documentation in the bag, so they think of solutions to achieve them. One approach is note cloning.
As fast and easy as it is, cloning spawns as many problems as it solves, leading to being tagged for issues in compliance and quality.
Fortunately, there is a way to avoid getting tagged while streamlining documentation. Here’s what you need to know:
What Is Note Cloning In Patient Documentation?
Cloning, sometimes called the copy-and-paste functionality depending on your EMR system, is the practice of copying and pasting previous progress notes, either partially or in their entirety, to document a recent appointment.
Cloning has become a common practice in patient documentation due to its speed and convenience. A 2017 meta-study using copy-and-paste functionality (i.e., cloning) in healthcare practices found that up to 90% of physicians use the feature regularly.
However, it poses many legal and regulatory risks to essential factors such as:
- Patient care quality - Patients may receive incorrect diagnoses or treatment that can compromise their recovery.
- Record integrity - A patient’s record history can become unclear and vague as new entries are added.
- Clinical workflow - Providers may scramble if they identified that some details in the documentation are erroneous, leading to delays.
- Billing - Issues such as duplicate claims, upcoding, and denials may increase.
Thus, federal and state regulations have arisen to control or ban note cloning, sanctioning practitioners and clinics that practice it.
Ways To Avoid Being Tagged For Cloning
Solving tagging issues related to cloning boils down to resolving the root issue of documentation time. While cloning may be a quick and easy way to streamline documentation, it has led to compromises in note quality and compliance, intentional or otherwise.
Therefore, the best way to avoid being tagged for cloning is to optimize your documentation workflow so that cloning is no longer necessary.
Here are a few ways how:
Utilizing Note-Taking Best Practices
- Shorthand techniques to capture vital details efficiently
- Practicing with mock appointments to train speed and focus
- Using a carefully placed audio recorder during the patient encounter
Cloning ensures progress note completeness in patient histories. Of course, note completeness differs from note quality, which is determined by how well it attunes to the treatment and findings in the appointment.
To streamline documentation without cloning, you must make every part of the process as efficient as possible. Note-taking is one aspect of documentation that can be significantly improved.
Typically, it takes time for a provider to encode their notes into the EMR. This is not only because of their own speed, but also because they must skim their notes and determine which details must be encoded. Sometimes, the provider must also remember the patient's appointment to recall details missed in their notes.
To resolve these issues, improve your note-taking speed during the appointment. Shorthand and other techniques can greatly speed up taking notes without missing details and compromising patient engagement. You can double down on note-taking speed and focus by practicing with mock appointments with a live partner.
Alternatively, you can use a HIPAA-compliant audio recording device, with the patient’s consent, to capture all details fully. This enables the provider to focus on the patient, improving satisfaction and engagement. Keep in mind, however, that skimming through the audio recording takes some time.
Regular Medical Review Sessions
- Note quality and consistency as a criterion
- Regularly scheduled based on provider availability
- Designating action steps for continuous improvement
If left unchecked, cloning can degrade record integrity over time. Thus, evaluating the quality of your patient records is a repeated effort.
Regular medical review sessions are an effective way of assessing record integrity and determining whether cloning occurred. This is also an opportunity for you to evaluate documentation expertise and identify potential opportunities for improvement.
For best results, schedule a review session at least twice a month based on your team’s availability. This ensures you can regularly achieve record quality and consistency and avoid too much backlog. Conclude each session with action steps tailored to each provider so they can continue their documentation skills consistently.
Cloning Regulations And Guidelines
- Regulating cloning practices for compliance
- Using an EMR that has a copy-forward feature with tags
- Providing regular training sessions that promote safe cloning practices
Cloning will continue to be a common practice for providers because of its convenience. Practically speaking, you cannot stop or discourage cloning among your team — but you can at least regulate how it should be done.
One of the most effective ways to regulate cloning and avoid tagging is to allow providers to clone only certain parts of past records. Often, this will be patient details and previous treatment plan steps that are reiterated from the past record to the new one. This approach is effective because it allows cloning while ensuring vital, up-to-date information is on the latest record.
Also, most EMR systems feature a “copy-forward” or “copy-and-paste” feature with labels indicating that the patient record (or parts of it) has been copied from a previous entry. This helps you identify cloned information and determine which parts should be updated or modified.
To solidify these guidelines, hold regular training sessions among your team to promote safe cloning practices. Focus on the urgency of addressing tagging issues and the importance of safe and effective cloning.
Using An AI Scribe Tool
- Fast, convenient, safe documentation notes
- Reduced documentation time and burden
- Must be HIPAA-compliant and compatible with your existing EMR
Artificial intelligence solutions are on the rise, helping providers deal with documentation issues efficiently.
AI scribes like ScribePT record the patient encounter in the background, automatically collecting information and generating an audio transcript for your perusal.
After the appointment, the tool will process the recording and generate AI SOAP notes for physical therapy that match your documentation style and structure. Once you review and edit your physical therapy SOAP notes, you can transfer them to your EMR with one click.
AI SOAP note tools can significantly reduce documentation time and burden, allowing you to focus on your patient while ensuring note quality is up to par.
Make sure that your chosen SOAP note tool protects patient information and is compatible with your current equipment. ScribePT, for example, is HIPAA-compliant and is compatible with any existing EMR.
AI Is The Key To Fast, Accurate Medical Documentation
Documentation continues to be a source of struggle for providers who want to provide the best possible patient experience. To this end, AI tools like ScribePT are invaluable in equipping rehab therapists to improve note quality, maintain compliance, and provide patients the care they deserve.
ScribePT is the best AI scribe tool that streamlines documentation for physical therapy practitioners. Contact us to learn how ScribePT can help you save over 40 hours per month!n workflow and take your practice to greater heights!
