Tuesday, September 27, 2016

Copy-Forward in Clinical Notes - Oh No; or No No

After working in health IT for several years now, I often hear older docs complain about the newer generation of computer physicians.  That is, that these young docs will rarely touch the patient but instead spend their time on the computer ordering tests and pouring over results and treating the tests and not the patient. I'm not about to weigh in on that issue; but another problem with this generation of computer guided doctors is their tendency to take short cuts in their clinical documentation.  For example, they might copy forward (aka clone or cloning, carry forward, copy and paste, cookie cutter, cut and paste, and others) content from one note to the next.  This post will talk about an application I wrote to detect this practice and offer some observations about what we found.