And that’s what makes documenting difficult. “What is the patient story for that day or that visit?” Warner says. In essence, practitioners should be storytellers. Practitioners should retain key patient history as well as updated notes so patients receive the most accurate care. 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. Monitor, measure, and assess copy and paste use consistently.Train and educate staff about the appropriate and safe use of copy and paste.Cite the origin of copy and paste material clearly.Make copy and paste material easily identifiable.In addition, the ECRI Institute held a workshop in 2016 that identified 4 safe practice recommendations for using copy/paste features: EHRs are great in that they allow doctors to more easily access and update patient information in real-time. However, these days, a patient’s chart is stored in an electronic health record (EHR). What review and editing is required of the provider so only relevant and up-to-date information is included in the document? When a doctor sees a patient, they keep track of what occurred during the visit.When should you copy and paste information?. Several questions should be asked when developing policies and procedures: 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. 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. 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.Īnd the practice is more common than one might think. 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. 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. “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). The feature can be fast, simple, and seems safe to use. It’s so easy to do-just use the “copy and paste” feature in an electronic health record (EHR), and all the prior information about a patient appears in the document.
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