In my work, I am pleased to see the wide implementation of Electronic Health Records. EHR applications have made a huge difference in how we practice psychotherapy. With the improvements in EHR platforms supporting clinical documentation has become a lot less arduous than handwritten notes. Well-developed EHR applications can be a real game changer to support the administrative work psychotherapists face every day. That said, EHR can also provide “bells and whistles” which can ultimately become problematic in appropriate documentation.
One of those features is the “Auto-Fill” function.
One of the things I see from my clinician clients when I review their records is how the auto-fill feature in progress notes can easily lead to notes ceasing to be extemporaneous and encroach on becoming “cloned”.
The community standard for progress notes is that they will be a “complete, concise, and accurate” reflection of the time spent with your client. A cloned note, a note which appears to be identical (or largely identical) for different sessions can put you and your practice at risk if they are reviewed for any reason and can lead to all sorts of problems with your payor source if you’re audited.
While it means a little more effort, the easiest way to address this issue is to turn off the auto-fill feature on your EHR application --CMS certainly recommends it -- and invest the bit more time it takes to effectively document the session. This adjustment can make an important defensive impact on your practice and will strengthen your progress notes at the same time.