In this episode, Dr. Junaid uses Mel Brooks’ “Young Frankenstein” to examine how clinical notes become monsters stitched together through rampant copy-forward and copy-paste, as documented by UCSF and Penn studies. He walks through the dangers of carried-forward errors and how AMA E/M guideline changes shifted billing away from exhaustive templated documentation, meaning much of the “tuxedo” clinicians still add to notes is unnecessary padding rather than a requirement. He offers physicians and APPs three ways to reclaim their voice and points listeners in need of more support to the Charting Conquered Blueprint.
Chart Less, Live More with Dr. Junaid Niazi. Halloween episode: the clinical note as a Frankenstein’s monster, and how to put your own brain back in it.
A Frankenstein Moment
Hello, and welcome back to Chart Less, Live More, the show for physicians and APPs who want to practice excellent medicine, think clearly about hard stuff, and still have an actual life outside their EHR.
I’m your host, Dr. Junaid Niazi. It’s Halloween week, so we’re doing a monster movie. A classic, which happens to be a comedy, Young Frankenstein, directed by Mel Brooks in 1974 and purposefully shot in black and white. Gene Wilder plays Frederick Frankenstein. He’s a respected scientist and physician teaching at an American medical school.
The movie opens with him lecturing a room full of medical students. One of them raises his hand and asks about his famous grandfather, the one who built a monster out of spare parts. And Frederick is so determined not to be that guy that he corrects the student on his own last name. It’s pronounced Frankenstein.
He goes on to tell the whole lecture hall with total conviction that his grandfather’s work was doo-doo. And then he inherits the family castle. And not long after, he’s in the lab, at night, in a thunderstorm, building the exact monster he swore he would never build. I think every clinician has a Frankenstein moment. Maybe it was in residency.
You watched and attending finishing notes at 10 o’clock at night, and you thought, that will never be me. I’m going to be efficient. I’m going to have a life. And then, a few years later, it’s 10 o’clock at night, and the lab is lit up, and you are building the thing.
The Note Is the Monster
So today we’re talking about the monster most of us build every single day without ever meaning to. And you know what it is. Say it with me. The note. Think about it. The modern clinical note really is a Frankenstein’s monster. It’s stitched together from other people’s parts. It’s dressed up for an audience that mostly isn’t paying attention. And it falls apart under bright lights. But the movie also has a happy ending. And the fix for the note is hiding in the final scene. We’ll get there. The original monster is assembled from other people’s body parts. That’s the whole premise.
How Much of Your Note Did You Write?
So let’s ask the same question about your note. How much of it did you actually write? In 2017, a team at UCSF analyzed more than 23,000 inpatient progress notes written by 460 clinicians. They tracked where every piece of text came from. Was it typed by hand, copied from somewhere else, or pulled in automatically by the EHR?
In a typical note, about 18% of the text was typed by the person who signed it. 18%. The rest was copied, about 46%, or imported, about 36%. For residents, it was even lower. Under 12% was typed by hand. Then in 2022, a team at Penn went much bigger. They examined more than 100 million notes over six years. About half of all the text in the record, 50.1%, was duplicated from earlier text. And that number was climbing every year, from about a third in 2015 to more than half by 2020. And guess what? Of all that duplicated text, nearly half came from a different author.
So most of your note was written by someone else. Some of them have retired. At least one of them, statistically, is a medical student who has since become a dermatologist and has not thought about this patient’s potassium in years.
Okay, now, to be clear, this isn’t a lecture about lazy clinicians. Copy-forward exists because the system asks for an enormous amount of text on an enormous number of patients in not enough time. Copying is what a reasonable person does under those conditions. But it means your note is less a piece of writing and more something assembled in the lab at night. And you never quite know what came attached to the parts.
Abby Normal: The Copy-Forward Problem
Which brings us to the brain. In the movie, Frederick needs a brain for his creature. So he sends his assistant, Igor, played by Marty Feldman, and yes, it’s Igor, not Igor, to the brain depository to steal one. And not just any brain, the brain of a brilliant scientist, a man described as a scientist and a saint. Igor gets there, picks up the jar, gets startled, and drops it. It shatters on the floor. So he looks at the shelf, grabs the jar next to it, and heads home.
Later, after the creature has come to life and is not behaving the way a brilliant scientist’s brain should, Frederick starts to get suspicious. And he asks Igor, very calmly, whose brain he actually put in. Igor thinks about it and tells him, Abby someone. Frankenstein asks, Abby who? Abby normal. The label on the jar said abnormal. Igor just carried whatever was on the shelf. That’s copy forward. It’s the physical exam finding from a visit three years ago, still sitting at the top of the list. The medication the patient stopped taking two cardiologists ago. Nobody put it there on purpose. Somebody carried a jar from the shelf, and nobody read the label. There’s an even smaller gag in the movie that makes the same point.
What Hump? Errors Hiding in Plain Sight
When Frederick first meets Igor, he politely offers his services as a surgeon. Perhaps he could help with the hump. Igor looks at him and says, what hump? And if you watch the movie closely, the hump switches sides more than once. Nobody in the movie ever says a word about it. That’s the left knee that becomes the right knee in the copied exam. It’s right there in plain sight. And everyone reading the note says, what hump? This isn’t just hypothetical.
The Joint Commission put out a patient safety alert on copy and paste in the EHR back in 2015. The problems they flagged included outdated information, errors carried forward, and notes so long that the important thing gets buried. Which is exactly how you end up with Abby normal in the lab.
Puttin’ on the Ritz: The Note in White Tie and Tails
Now for the scene everybody remembers. Frederick has the creature somewhat under control, and he decides it’s time to show the scientific world what he’s accomplished. He rents a theater, fills it with distinguished guests, and presents the creature in white tie and tails.
Then the two of them do a song and dance to Puttin’ on the Ritz. Top hats, canes, some tap dancing. And for about a minute, it works. The audience is impressed. Then a stage light blows up and the creature panics, and the whole act falls apart in front of everybody. The creature here is the note, dressed up for billing and the inside of a courtroom.
The 14 system review of systems. The full templated exam. The paragraph of reassuring negatives. White tie and tails. It looks very impressive, right up until a stage light blows, an audit, a chart review, a deposition, or, honestly, the most common one, another clinician at two in the morning scrolling through six pages trying to find what you actually thought was going on. And here’s what makes it a little absurd.
Most of the Tuxedo Isn’t Required Anymore
A lot of the tuxedo isn’t required anymore. Starting in January 2021, the rules for office and outpatient visit levels changed. The level is now based on your medical decision making, or on your total time. History and exam only need to be what the AMA calls medically appropriate. In 2023, most of the other visit types followed. So the full ROS that your template still drops into every note? For most visits, it doesn’t move the billing level. It’s a costume. And it’s holding a cane and wearing a top hat. And it’s mostly an American costume.
In 2018, three physicians from Stanford, Harvard, and UC San Diego looked at data from Epic and found that American clinical notes were about four times as long as notes in other countries using the same software. Their explanation was that notes elsewhere contain the essential clinical information, and American notes carry a load of compliance and reimbursement documentation on top of it. That’s not a fact about medicine. It’s a fact about the rules we practice under, and the habits we built to survive them.
The Fix: Put Your Own Brain Back In
Back in the intro, I said the fix was hiding in the last scene. Here it is. By the end of the movie, there’s an angry mob at the castle, with torches, of course. And Frederick does something nobody expects. He hooks himself up to the machine and transfers part of his own mind into the creature.
When it’s over, the creature stands up, faces the mob, and talks. Clearly, thoughtfully. He explains himself, and the crowd calms down. The monster didn’t need more parts. It needed its maker’s brain. That’s the fix for the note. Put your own brain back in.
Three Things to Try This Week
Here’s three things you can try this week.
- Write your thinking first. Before anything else in the note, write three sentences in your own words. What you think is going on, why you think so, what happens next. That’s your medical decision-making, and under the current rules, that’s the part that actually counts.
- Read the label on one jar. Pick one block of carried-forward text in a note this week. An exam, a problem list, a med list, and actually verify it. If it’s still true, keep it. If it’s not, delete it. Remember, Igor’s mistake was not reading the label.
- Take off one piece of the tuxedo. Find one templated section that’s in every note out of habit, like the full ROS. Check it against your organization’s coding and compliance guidance. If it’s not required for the visit, take it out. And if your organization’s template is the thing forcing the tuxedo on everybody, that’s worth raising with whoever owns the template. That’s not a you problem. That’s a whole castle problem.
Fix the Castle, Not Just the Monster
Oh, and before I let you go, if the note is where you’re struggling right now, don’t stress. You’re in good company. I hope these three tips help. Write your thinking first, read the label on one jar, take off one piece of the tuxedo. Even one of those will make a difference this week. But if you find you want more support than that, the note is usually just the part you can see.
A lot of what makes charting hard is how the whole day is built, when you make decisions, when you document them, and how many times you end up making the same decision twice. That’s what Charting Conquered Blueprint is for. It’s a self-paced course, and it works on the whole clinical day, so the charting gets done while you’re with the patient, not at 10 o’clock at night in the lab. Less fixing the monster, more fixing the castle.
Remember, struggling with charting isn’t a character flaw. The link is in the show notes.
Make the Note Yours
Here’s where I want to leave you. Frederick spends the first half of that movie running from his own name, Frankenstein. He’s embarrassed by the family business. He swears he’ll never do it. By the end, he stops running. He says the name the way it’s actually spelled. He owns it. The note isn’t going anywhere. It’s part of the family business. But you don’t have to keep building it out of other people’s parts. You don’t have to run from the note. You just have to make it yours.
If this episode made you think of a colleague who’s still in the lab at 10 o’clock at night, send it to them. And if you have a few minutes, leave a review. It helps other physicians and APPs find this podcast.
Happy Halloween! I’ll see you next time.
Sources and Contact
Content for this episode includes proprietary information from Prosperous Life MD and Charting Conquered, along with research published in JAMA Internal Medicine, JAMA Network Open, and the Annals of Internal Medicine. The Joint Commission’s 2015 Quick Safety Advisory on Copy and Paste, and the AMA’s 2021 and 2023 E&M Guidelines.
Full citations are in the show notes. It also includes the personal opinions and experiences of Dr. Junaid Niazi.
For questions or comments, please email support@prosperouslifemd.com and include podcast in your subject line.