Cloning Notes
Cloning Notes
A Risky Shortcut in Clinical Documentation
A Risky Shortcut in Clinical Documentation
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Audience: Clinical Providers
Tools Used: Articulate Rise 360, Microsoft PowerPoint, Microsoft ClipChamp, ChatGPT
Responsibilities: Instructional Design (action mapping, storyboarding, visual design, prototyping, authoring), eLearning Development
Situation:
A hospital system client had recently experienced a compliance issue involving a provider who copied and pasted notes across multiple patient visits in their EHR. This practice—known as cloning notes—was flagged during an internal audit as a billing risk, raising concerns about documentation integrity and potential regulatory violations. The client needed a fast, effective way to educate providers on what constitutes cloned notes and how to avoid them within the constraints of the new EHR system.
Task:
I was asked to create a concise, engaging training that would clarify the definition and risks of cloned documentation, demonstrate compliant alternatives, and offer practical guidance—all in a format that could be delivered asynchronously and completed quickly by busy providers.
Action:
Using the ADDIE model, I approached this project with a clear focus on developing a concise, impactful microlearning experience tailored to the documentation challenges faced by healthcare providers in a high-risk compliance environment.
Result:
The hospital was so satisfied with the clarity and impact of the Cloning Notes training that they made it mandatory for all providers across the system. The success of the module led them to request additional microlearning topics to further support billing compliance, setting the foundation for a scalable education initiative integrated into provider onboarding and ongoing training.
ADDIE:
Analyze: Following the identification of a provider cloning notes across multiple patient visits—flagged during an internal audit—I collaborated with compliance stakeholders to understand the urgency and scope of the issue. While the behavior was isolated, it revealed a need for system-wide education to reinforce documentation standards under the new EHR environment. I reviewed the audit findings and conducted external research to better understand how cloned documentation contributes to regulatory violations and financial risk. Grounded in adult learning principles, I determined that a brief, scenario-based microlearning course would be the most effective and scalable solution for busy healthcare providers.
Design: To shape the course content, I conducted external research on the regulatory and financial risks of cloned documentation, including payer audit triggers, overbilling concerns, and enforcement actions tied to note cloning. This research informed the narrative and examples used in the training. I drafted learning objectives using Bloom’s Taxonomy and structured the course using Gagné’s Nine Events of Instruction—starting with a realistic, high-stakes scenario, followed by guided practice through a sorting activity and reinforced with a downloadable job aid to support daily documentation decisions.
Develop: I developed the course in Rise 360, using concise language, realistic visuals, and interactive sorting exercises to simulate common EHR documentation behaviors. The design emphasized relevance, clarity, and efficiency, with a total runtime under 10 minutes. I collaborated with internal auditors and compliance stakeholders to ensure the clinical and regulatory accuracy of the scenarios and takeaways.
Implement: The course was published in the hospital’s LMS and quickly made mandatory for all providers to ensure system-wide understanding and prevent similar incidents. Its mobile-responsive, asynchronous format allowed providers to complete it flexibly, and compliance staff were given the option to assign the course as part of audit remediation protocols moving forward.
Evaluate: I applied Kirkpatrick’s Evaluation Model (Levels 1 and 2) by embedding feedback prompts and knowledge checks throughout the module. Learners responded positively to the format and clarity, and the success of the training prompted the hospital to request additional microlearning modules addressing other billing compliance topics.
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