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Cranking Out Notes, Ethically and Efficiently, Ep. 03

Light Up The Couch

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Do You Copy and Paste Your Clinical Progress Note?

In a perfect world, your progress note also encourages your clinical reflective process. But trust me here, once you get past a potentially steep learning curve of how to integrate these elements from these trainings, it really should only take you five or ten minutes in order to write an effective progress note. Our next section relates to copying and pasting. There have been many examples over the years, both on a national basis and in California, that relate to insurance fraud and third party billing fraud. On an audit, copy and pasted content is a major, major red flag. The accreditation agencies like the Joint Commission and CARF specifically require that charts are individualized.

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