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October 19, 2019 01:00 AM
Update July 2021 Issue: The use of the copy-and-paste function (CPF) in health care provider’s clinical documentation improves efficiencies, however CPF can promote note bloat, internal inconsistencies, error propagation, and documentation in the wrong patient chart,1 potentially putting patients at risk. A workgroup convened by the Partnership for Health IT Patient Safety conducted a literature review that identified 51 publications; one study of diagnostic errors found that CPF led to 2.6% of errors in which a missed diagnosis required patients to seek additional unplanned care. The workgroup found several case reports of clinical harm related to CPF, including a patient who died from a heart attack after his primary care physician (PCP) failed to diagnose cardiac disease. Two years prior, the patient was discharged from the emergency department after a new diagnosis of atrial fibrillation and potential heart disease; he was instructed to follow up with his PCP for a stress test. The PCP copied and pasted the Assessment and Plan (A/P) section of the patient’s record for 12 office visits during the next two years, updating the A/P or reviewing medical entries from the ED or other department. The PCP was found liable in the death.1 Safety Actions to Consider: All organizations that use EHRs should be aware of the potential risks of the CPF and collaborate with their health care providers to ensure this tool does not lead to unintended consequences that may result in patient harm. There are actions that health care organizations can take to help prevent copy-and-paste errors in EHRs, including the following recommendations from the Partnership for Health IT Patient Safety workgroup and the American Health Information Management Association:
In addition, the following recommendations from The Joint Commission can further support the safe use of the CPF in EHRs:
Resources:
Additional resources: Partnership for Health IT Patient Safety Health IT Safe Practices: Toolkit for the Safe Use of Copy and Paste. February 2016. Includes implementation aids for organizations, including a training checklist, educational presentations, risk identification assessments (tailored for various stakeholders), self-assessment checklists, templates for policies and procedures, implementation plans and strategies for stakeholder groups, and audit and assessment tools which can be used to assess successful implementation. Note: This is not an all-inclusive list. What should be considered when deciding whether to use the copy and paste functionality?Users of the copy/paste functionality should weigh the efficiency and time savings benefits it provides against the potential for creating inaccurate, fraudulent, or unwieldy documentation. Why should the copy and paste function not be used in the electronic health record?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. What is the potential impact of the copy paste functionality on the integrity of the data and information contained in an EHR?Using the copy functionality in an EHR system poses risk to documentation integrity, including: Inaccurate or outdated information that may adversely impact patient care. Inability to identify authors or what they thought. Inability to identify when the documentation was created. What is the advantage 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 you not copy and paste in EHR?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.
What is the potential impact of the copy paste functionality on the integrity of the data and information contained in an EHR?Using the copy functionality in an EHR system poses risk to documentation integrity, including: Inaccurate or outdated information that may adversely impact patient care. Inability to identify authors or what they thought. Inability to identify when the documentation was created.
What risks are there in copying and pasting?“Copying and pasting lots of information runs the risk of upcoding, and also the risk of creating a medical record that is so loaded with text and repeated information that it is almost impossible to tell what happened and when.
Is copy and paste an acceptable form of patient care documentation?Using the copy and paste function with electronic medical records is a questionable ethical and legal manner in which to document patient care. ”Cloned” documentation is often done when trying to save time and/or when the patient has not been fully assessed, leading to errors continuously being forwarded in a patient's ...
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