Published May 7, 2018 But is it? According to experts, not always. “Why is copy and paste a bad idea? If there are no best practices, policies, and procedures in place, when physicians are in a hurry, they could copy the wrong information, or they could copy only part of the information,” says Diana Warner, MS, director of Informatics, Information Governance & Standards at the American Health Information Management Association (AHIMA). Overuse or incorrect use of the copy and paste feature in EHRs can be dangerous and can have legal ramifications, including insurance fraud or loss of money from billing errors due to convoluted information for coding, Warner says. Also called “cloning” and “carrying forward,” the copy and paste feature has benefits—including saving time during vital documentation, which is especially useful with the heightened importance of the EHR Incentive Program (also known as “Meaningful Use”)—but the risks can be high. In “Appropriate Use of the Copy and Paste Functionality in Electronic Records,” AHIMA notes that using copy and paste incorrectly can result in “redundant, erroneous, and/or incomprehensible health record documentation.” For example, if a patient has a family history of breast cancer but no diagnosis of the disease and a practitioner accidentally copies only “breast cancer,” leaving off “family history of,” the patient’s medical history would then be inaccurate, Warner says. And the practice is more common than one might think. An August 2017 study in JAMA® found that, of 23,630 notes written by 460 clinicians, more than 80% of text was copied or imported from a previous document. Only 18% of text was manually entered. With so many practitioners using the copy and paste feature, more awareness about potential issues, as well as collaborative solutions from all involved, is needed, Warner says. Several questions should be asked when developing policies and procedures:
In addition, the ECRI Institute held a workshop in 2016 that identified 4 safe practice recommendations for using copy/paste features:
Not all information needs to be copied from previous notes and other documents, and knowing what to edit can help prevent “note bloat,” when documents such as progress reports become overwhelming from copying too much content, Warner says. Practitioners should retain key patient history as well as updated notes so patients receive the most accurate care. In essence, practitioners should be storytellers. “What is the patient story for that day or that visit?” Warner says. “Sometimes it gets lost. And that’s what makes documenting difficult.” Skip to main content
October 19, 2019 01:00 AM
What are some of the dangers with the copy and paste functionality of a medical record?Copy and paste can promote note bloat, internal inconsistencies, error propagation, and documentation in the wrong patient chart.
What are the benefits of copy and paste?ECRI points to these positive results from the prudent use of copy-and-paste, saving time by allowing for information that does not readily change to be easily transferred, efficiently capturing complex information, improving tracking of multiple problems for complex patients by providing an easy way to continually ...
Why should the copy and paste function not be used in the electronic health record?Use of the copy and paste (copy/paste) functionality in EHRs can result in redundant, erroneous, and/or incomprehensible health record documentation.
Can you copy and paste in medical records?Clinical providers are permitted to use the “copy and paste” functionality when documenting within electronic medical record systems for the purpose of patient care. Clinical providers are responsible for the total content of their documentation, whether the content is original, copied, pasted, or reused.
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