Note Cloning

[Phipps]

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What do you all think about note cloning, as defined by copying and pasting your own previous notes with little change? What if you notice another provider copying and pasting your note verbatim without indicating original authorship? Thanks for any and all thoughts

 

[Phipps]

What do you all think about copying and pasting a note from a previous session? What if you notice another provider, copying and pasting your assessment, signing with their name? Any thoughts are appreciated.

 

[MCParent]

What do you all think about note cloning, as defined by copying and pasting your own previous notes with little change? What if you notice another provider copying and pasting your note verbatim without indicating original authorship? Thanks for any and all thoughts

In my experience people who do this for notes or reports need to spend more time checking names/pronouns and changing the specifics than I ever spend writing a clinical note/report from scratch (or they don’t check and their notes/reports are a mess).

 

[Sanman]

This thread is the highest form of irony.

 

[Phipps]

This thread is the highest form of irony.

…true and also reality

 

[WisNeuro]

In medicolegal work, having to review countless notes from many, many providers, this is the norm as opposed to the exception. I recently had a case where over the course of 3+ years, a provider only used 5 different notes and seemingly mixed those notes in randomly. IME LPCs/LPCCs tend to do this much more often than other providers.

 

[cara susanna]

Copying and pasting your notes and then modifying them?

 

[WisNeuro]

Copying and pasting your notes and then modifying them?

Definitely, this is the heart of templating. There are note elements that should be very similar or the same. But, for what you actually did/covered/discussed in session, that should definitely have some variability.

 

[WisNeuro]

I also love notes where there is a section labeled "Interventions administered" or something similar and it reads like the following

"CBT, DBT, managing stressful emotions, Integrative, Thought Processing, Identification of Distorted Thinking, Attachment, Dynamic Processing, Reiki, Thetan Processing......"

The last few I haven't seen yet, but just last week I reviewed years of notes that just listed off a mix of 15 modalities/techniques copy/pasted into the note. MAde for interesting commentary when I had to map that on to statutes for treatment that qualified for compensation.

 

[AcronymAllergy]

Mod Note: Merged the two threads into one.

 

[Therapist4Chnge]

The structure of the note is fine to template out, but the content needs to be written. All of my notes and reports follow a clear structure, but it’s more like sentence stems.

“In regard to [reported pain/sleep/physical functioning]…

“Goals include…”

The topic order may vary in my progress notes, but doing so creates a familiar format that is easily read when reviewing. My notes lists all of the required billing info first, then a brief overview of topics covered, then recs.

In contrast, my counselor copies and pastes and updates in sections, which results in longer and longer sections. She’s a contractor and I provided feedback, but she prefers her style. As long as she includes the required billing stuff and the treatment is documented, good enough.

 

[AcronymAllergy]

I also have no problem with copy-pasting and modifying; like WisNeuro said, that's basically just a template. The presenting complaints and history up to that point aren't going to have changed with each new session, for example. Some of the best notes I've seen were long, but included a running summary of essentially the entire treatment history to that point.

But if the actual session content is identical or nearly so, the notes become pretty useless.

 

[PsyDr]

This depends on your perceived purpose of the note.

If the purpose is for insurance billing, then there is no issue.
If the purpose is to serve as a proxy for memory, then the notes should be much more thorough. However, there will be legal implications for that.
If the purpose is to communicate between healthcare providers, then there is no issue because the details of psychotherapy are generally irrelevant for medical treatment. And usually there are curbside consults for real issues.
If the purpose is to communicate to another therapist, then it depends on the other therapist.
If the purpose is to defend yourself from liability, then there is no issue because extra information can only harm you.

 

[cara susanna]

This depends on your perceived purpose of the note.

If the purpose is for insurance billing, then there is no issue.
If the purpose is to serve as a proxy for memory, then the notes should be much more thorough. However, there will be legal implications for that.
If the purpose is to communicate between healthcare providers, then there is no issue because the details of psychotherapy are generally irrelevant for medical treatment. And usually there are curbside consults for real issues.
If the purpose is to communicate to another therapist, then it depends on the other therapist.
If the purpose is to defend yourself from liability, then there is no issue because extra information can only harm you.

Really? Lawyers wouldn't go after that in the event of a legal issue? I mean, if NOTHING about the note changes?

 

[WisNeuro]

Really? Lawyers wouldn't go after that in the event of a legal issue? I mean, if NOTHING about the note changes?

Depends. In my work, I just generally comment something to the effect that the diagnosis X was never adequately established within the documentation provided to me. Usually because there was never a diagnostic assessment, or the DA never listed the presence, severity, or frequency of symptoms.

 

[AcronymAllergy]

Depends. In my work, I just generally comment something to the effect that the diagnosis X was never adequately established within the documentation provided to me. Usually because there was never a diagnostic assessment, or the DA never listed the presence, severity, or frequency of symptoms.

"Individual is reporting sleep problems and posttraumatic symptoms. They obviously have PTSD." /end

 

[WisNeuro]

"Individual is reporting sleep problems and posttraumatic symptoms. They obviously have PTSD." /end

Yeah, if they mention thinking about it and bad dreams at all, it's usually an instant PTSD diagnosis

 

[smalltownpsych]

I had a deposition recently where they went through my notes for a former patient. It reinforced why I've always kept psychotherapy notes pretty minimal. I document what I need to document, but I don't try to put all of my clinical thinking into the record.

The exception is risk—suicide risk, hospitalization, safety, etc. Then I document more because I want a record of what I considered and why I made the decision I did.

When they wanted to know more about my clinical reasoning than what was in the notes, I just testified to it.

My takeaway: document enough to show you did your job, but don't write the opposing attorney's deposition questions for them.

 

[WisNeuro]

I had a deposition recently where they went through my notes for a former patient. It reinforced why I've always kept psychotherapy notes pretty minimal. I document what I need to document, but I don't try to put all of my clinical thinking into the record.

The exception is risk—suicide risk, hospitalization, safety, etc. Then I document more because I want a record of what I considered and why I made the decision I did.

When they wanted to know more about my clinical reasoning than what was in the notes, I just testified to it.

My takeaway: document enough to show you did your job, but don't write the opposing attorney's deposition questions for them.

I'll add in, actually document enough to justify a diagnosis if you are making one. It is exceedingly rare to see someone actually document a coherent timeline, along with current symptom and frequency of symptoms to justify a diagnosis. But then again, when you don't do this, my job is easier a lot of the time 🙂

 

[smalltownpsych]

I'll add in, actually document enough to justify a diagnosis if you are making one. It is exceedingly rare to see someone actually document a coherent timeline, along with current symptom and frequency of symptoms to justify a diagnosis. But then again, when you don't do this, my job is easier a lot of the time 🙂

I think that’s a good point and will typically document the criteria on my intake and if it’s an assessment that should obviously be included. When doing an intake I do tend to have the symptoms in different sections though, some in hx, some in mental status, and at the end if I think it’s key, my EHR has a little section by the diagnosis for other reasoning clinical rationale so I might just throw it in there.

Also, as relates to the current media case with post partum depression, some clinical presentations Im going to document more than others. An early career psychologist that consults with me frequently seems to get a lot of potentially dangerous young men on his case load for whatever reason and documenting the consult and the steps and recommendations is a big part of what we consider. I believe that cya and appropriate treatment aren’t mutually exclusive, in fact they tend to go hand in hand. I was taught that one should think about how you would explain your rationale if an and outcome happened and you were brought into court.

 

[Sanman]

I'll add in, actually document enough to justify a diagnosis if you are making one. It is exceedingly rare to see someone actually document a coherent timeline, along with current symptom and frequency of symptoms to justify a diagnosis. But then again, when you don't do this, my job is easier a lot of the time 🙂

Its funny you say that just got off a PTSD vs panic disorder intake and the guy cannot recall a timeline of onset, ftequency of sx, does not yake his psych meds as prescribed, and records are spotty at best. I need to make a dx for the intake, but it is going to be a shot in the dark based on the info.

 

[WisNeuro]

Its funny you say that just got off a PTSD vs panic disorder intake and the guy cannot recall a timeline of onset, ftequency of sx, does not yake his psych meds as prescribed, and records are spotty at best. I need to make a dx for the intake, but it is going to be a shot incthe dark based on the info.

Yeah, that would be odd, in my experience, unless the symptoms started decades ago. Usually my PTSD and panic patients had a pretty good recall of when they started having panic attacks, and are pretty good about knowing at least some environmental triggers.

 

[cara susanna]

Its funny you say that just got off a PTSD vs panic disorder intake and the guy cannot recall a timeline of onset, ftequency of sx, does not yake his psych meds as prescribed, and records are spotty at best. I need to make a dx for the intake, but it is going to be a shot incthe dark based on the info.

This is why the lord invented rule-outs

 

[Sanman]

Yeah, that would be odd, in my experience, unless the symptoms started decades ago. Usually my PTSD and panic patients had a pretty good recall of when they started having panic attacks, and are pretty good about knowing at least some environmental triggers.

Yeah symptoms started decades ago. Guy in his 70s with terrible recall regarding history, functional agoraphobia, as well as physical problems that make it difficult to leave home . No treatment other than some psych meds and good old ETOH abuse. Combat vet + corrections officer. Just the logistical difference between clinical and forensic work. I will pick a dx and a rule out and move on based on the few records I have. Don't have the luxury of time.

 

[R. Matey]

This is why the lord invented rule-outs

and Unspecified 🙂

 

[WisNeuro]

Yeah symptoms started decades ago. Guy in his 70s with terrible recall regarding history, functional agoraphobia, as well as physical problems that make it difficult to leave home . No treatment other than some psych meds and good old ETOH abuse. Combat vet + corrections officer. Just the logistical difference between clinical and forensic work. I will pick a dx and a rule out and move on based on the few records I have. Don't have the luxury of time.

No doubt, one of the reasons I love lengthy record review. Especially when I have a decade plus preceding anything. Pays well, but more importantly, gives a pretty good view of someone's symptom and functional status. Which, in most cases, didn't change after whatever incident happened that they are currently in litigation about.

 

[MiniLop]

What do you all think about note cloning, as defined by copying and pasting your own previous notes with little change? What if you notice another provider copying and pasting your note verbatim without indicating original authorship? Thanks for any and all thoughts

 

[futureapppsy2]

This is why the lord invented rule-outs

I have seen people--mostly laypeople but a few professionals as well--interpret "rule-out" as "this was ruled out", not "need to rule this out."

 

[AcronymAllergy]

What do you all think about note cloning, as defined by copying and pasting your own previous notes with little change? What if you notice another provider copying and pasting your note verbatim without indicating original authorship? Thanks for any and all thoughts

I'm fine with copying-and-pasting prior note content for information that hasn't changed and is still relevant. But I think each note should still have a portion unique to that encounter to discuss what was actually done in the session.

It's usually bad form/a faux pas to copy straight from someone else's note without indicating where that information came from, but I'm not sure there's much you can do about it, unless the person is mischaracterizing what you've said. In which case, messaging/calling the provider could be worth a shot. Barring that, you could create an addendum to their note.

 

[WisNeuro]

I'm fine with copying-and-pasting prior note content for information that hasn't changed and is still relevant. But I think each note should still have a portion unique to that encounter to discuss what was actually done in the session.

It's usually bad form/a faux pas to copy straight from someone else's note without indicating where that information came from, but I'm not sure there's much you can do about it, unless the person is mischaracterizing what you've said. In which case, messaging/calling the provider could be worth a shot. Barring that, you could create an addendum to their note.

Yeah, I assume most of us in neuro are used to copy/pasting relevant portions of notes (e.g., MRI/CT results, Impressions/Summary from a previous eval), but yeah, I specify the provider and date of that note, and quote verbatim, saving my own interpretation in my summary if need be.

That's for clinical, obviously we quote stuff from other providers liberally in medicolegal work. Though, some also do not do this ethically/intelligently. We got an opposing expert's opinion thrown from a case because he frequently used quotes to refer to other experts/providers, but the phrases within the quotes were not verbatim and included his own editorializing and additional words thrown in to mischaracterize what was said.

 

[Fan_of_Meehl]

Its funny you say that just got off a PTSD vs panic disorder intake and the guy cannot recall a timeline of onset, ftequency of sx, does not yake his psych meds as prescribed, and records are spotty at best. I need to make a dx for the intake, but it is going to be a shot in the dark based on the info.

If it truly is panic disorder (and actual panic attacks) then for most patients their first panic attack tends to be seared into their memory. Failing that, an approximate date/epoch of onset should definitely be doable for the interviewee. At least nailing down 'did you start having panic attacks in college (20 years ago) or last week' seems reasonable. However, in VA settings, my experience with trying to nail down timelines regarding onset 99.9% of the time devolve into the (unhelpful) dichotomy of either (a) during/at the end of my military service or (b) I have no clue when in my lifetime any of this started.

I have started leaning heavily on unspecified diagnoses toward the beginning of knowing patients these days (first 1-4 clinical encounters) when this is called for. I'm not averse to using unspecified anxiety disorder and/or unspecified depressive disorder. At the end of the day (at the clinical level) these are merely working clinical hypotheses (under the increasingly beleaguered 'latent disease model' of mental illness). Unfortunately, the reality in VA settings is that, once given, a PTSD diagnosis is viewed as permanent since nobody will be willing to 'touch it' or alter it given the high likelihood of everyone losing their minds and creating Hell for the person daring to reconsider that particular diagnostic determination.

 

[Sanman]

If it truly is panic disorder (and actual panic attacks) then for most patients their first panic attack tends to be seared into their memory. Failing that, an approximate date/epoch of onset should definitely be doable for the interviewee. At least nailing down 'did you start having panic attacks in college (20 years ago) or last week' seems reasonable. However, in VA settings, my experience with trying to nail down timelines regarding onset 99.9% of the time devolve into the (unhelpful) dichotomy of either (a) during/at the end of my military service or (b) I have no clue when in my lifetime any of this started.

I have started leaning heavily on unspecified diagnoses toward the beginning of knowing patients these days (first 1-4 clinical encounters) when this is called for. I'm not averse to using unspecified anxiety disorder and/or unspecified depressive disorder. At the end of the day (at the clinical level) these are merely working clinical hypotheses (under the increasingly beleaguered 'latent disease model' of mental illness). Unfortunately, the reality in VA settings is that, once given, a PTSD diagnosis is viewed as permanent since nobody will be willing to 'touch it' or alter it given the high likelihood of everyone losing their minds and creating Hell for the person daring to reconsider that particular diagnostic determination.

Pretty much, this person is also homebound due to physical health conditions as well as the possible agoraphobia (telehealth visit) , so avoidance of triggers (and life) is an issue at this point. I usually include a "by history" tag on most PTSD dx because I am not arguing with everyone about something I am not usually treating.