Question

A physician copies and pastes his progress note from two days ago into his most current note, adding a brief comment that there is no change in the patient’s condition.
Progress note 11/4/15 Patient showing improvement in breathing. Responding well to antibiotic. Able to get out of bed and move around with assistance. Performed a bedside debridement of a lower leg ulcer, excisional, subcutaneous.
Progress note 11/6/15 Patient showing improvement in breathing. Responding well to antibiotic. Able to get out of bed and move around with assistance. Performed a bedside debridement of a lower leg ulcer, excisional, subcutaneous. No change. Continued improvement.
Is this appropriate? Tell why or why not.

Answer 1

A physician copies and pastes his progress note from two days ago into his most current note, adding a brief comment that there is no change in the patient’s condition.

It is totally inappropriate because...

1. In his note of 11/4/15, he wrote "Patient showing improvement in breathing. Responding well to antibiotics". It seems there is a respiratory infection inpatient.

In his note of 11/6/15, he wrote the same thing again but he should have to describe whats are the improvement is like, ventilator setting changed or chest x-ray is clear or tachypnea resolved.

In the second line, he wrote "bedside debridement of a lower leg ulcer" on both dates but he did not describe what is the wound condition and is it better on 11/6/15.

Physician notes should completely reflect the patient's condition in detail.