The practice of copy/paste in electronic health records (EHR) is receiving heightened scrutiny lately, with a recent study finding that only 18% of records examined were entered manually – 46% were copied and another 36% imported, opening up the possibility of carrying forward outdated patient information from one record to another. The copy/paste function (CPF) was intended to save you time, but is the convenience worth the compliance risks?
To discover when exactly you can safely copy/paste and when you’re better off entering data manually, expert speaker Jill Young shares current guidelines directing the practice – so you’ll have an edge on maintaining accurate patient records. In her live audio conference “Cut & Paste: Medically Necessary Documentation – Or Clinical Plagiarism?,” Young sets you up for success with data entry best practices should the Center for Medicare & Medicaid Services (CMS) come knocking.
Problem: Too Much Wrong Information
The CPF, when used wisely, has quite a few advantages, such as reducing the time required to enter information into a patient’s record. However, like most other helpful tools, caution should be exercised when using it. The Joint Commission (TJC) records several issues with using the CPF too liberally, such as:
- Inaccurate and/or outdated information carried through the patient’s record
- Redundant and/or inconsistent information sprinkled through the EHR
- Increased risk of safety to patients (for example, an outdated patient’s weight in the EHR could lead to an incorrect dose calculation for their medication, putting the patient at risk)
An overuse of copy/paste can also lead to “note bloat,” which, similar to redundant information, inflates the amount of information in the EHR to such a degree that it’s difficult for physicians to quickly sift through the information to find exactly what they need.
Solution: Create a CPF Policy
Typically, upon recognizing a problem, a quick fix would be to implement rules set out by CMS or the TJC. In this case, though, there are none. CMS does have a guideline, which is somewhat helpful. It says:
“The medical record must contain documentation showing the differences and the needs of the patient for each visit or encounter. Simply changing the date on the EHR without reflecting what occurred during the actual visit is not acceptable.”
In other words, there’s a real difference between simple copy/paste (conscientiously copying relevant tidbits of information from one note into the appropriate section on another) and cloning (completely copying one note to another, changing maybe only the date). But CMS doesn’t offer explicit instructions on how to use the CPF appropriately.
So what to do? If the auditor comes around, you can’t simply use the “there’s no rule” excuse – you could still face penalties if too much or the wrong information was copy/pasted in the EHR. To prevent audit findings, consider creating a “wise use” CPF policy for your practice, such as the one the UC San Diego Compliance Program uses, to communicate clearly and consistently to all relevant staff what is and is not acceptable.
Remember: No one is arguing that the CPF is bad; rather, it’s a tool that should be used wisely and only as a supplement to inputting information manually. Used well, the CPF can increase efficiencies and foster more prompt communication.
Take Compliance a Step Further
To practice strict compliance with your CPF policy, the American Health Information Management Association (AHIMA) recommends that you:
- Develop specific procedures addressing the proper use of copy/paste to ensure compliance with all guidelines and industry standards
- Provide comprehensive training of appropriate copy/paste use to all EHR system users
- Monitor compliance, enforce policies and procedures, and institute corrective action as needed
Final to-do: Always double-check your work after copy/pasting. Many copy/paste errors result from unintentional mistakes, so be sure to always check the accuracy of the latest record before hitting “save.” By doing so, says Young, you’re doing your part to be audit-ready and ensure the integrity of your patient’s data records.