Knowledge Base Article

If you have ever audited electronic healthcare medical records, you have likely seen patients that are the same one day as another – exactly the same – no, I mean EXACTLY the same - the exact same wording of the patient’s condition, patient statements, treatment plan and/or other documentation elements. This is the result of “copy and paste” within an electronic medical record.

There are benefits and risks associated with the use of “copy and paste” within EHRs as described by the Partnership for Health IT Patient Safety. Benefits include time savings and a more efficient way to capture complex information which may result in improved tracking of multiple problems and improved continuity of care. It can also reduce transcription errors and omissions of important information. However, the outdated, inaccurate, irrelevant, and misleading information that can result from “copy and paste” erodes confidence in the record, may have medico-legal implications, and can result in more queries and work to determine if the information is correct. Charts and notes can become overwhelmingly long and effective communication is compromised because important findings and problems are intertwined with normal patient information, making it difficult to decipher what is important or current.

In response to safety concerns, the Partnership for Health IT Patient Safety developed a Toolkit for the Safe Use of Copy and Paste. Although the focus of the toolkit is patient safety, other concerns associated with “copy and paste” include billing and compliance issues and potential malpractice implications.

The recommendations provided in the toolkit and listed below are not intended to impair usability of EHR systems or impede workflow. Their goal is to allow providers the opportunity to evaluate the best ways to see the information that is being reused and to take steps toward the safe use of “copy and paste.”

Recommendation A: Provide a mechanism to make copy and paste material easily identifiable.

• Allows verification of accuracy and facilitates review for edits
• Potential Actions: Create policies and procedures; block certain areas of documentation from copying; have a different appearance for copied material (italics, different color, etc.)

Recommendation B: Ensure that the provenance of copy and paste material is readily available.

• Helps verify that the information is appropriate and accurate and increases the potential to defend the record and achieve billing compliance
• Potential Actions: Identify original source of information and track changes and authors

Recommendation C: Ensure adequate staff training and education regarding the appropriate and safe use of copy and paste.

• Helps providers understand their liability and the potential patient safety and compliance risks of copy and paste
• Potential Actions: Provide regular training and feedback; identify methods to verify current and correct information

Recommendation D: Ensure that copy and paste practices are regularly monitored, measured, and assessed.

• Ensures the integrity of the clinical record, the quality and safety of care rendered, and compliance with state and federal regulations
• Potential Actions: Create auditing policy; perform regular audits and report findings and provide feedback

I personally think this toolkit offers excellent recommendations for the safe use of a “copy and paste” function. As explained in the Toolkit, some of the recommendations will take time to implement, particularly those that require technology changes by developers and workflow changes for providers. However, there are some steps that hospitals could implement now to improve the use “copy and paste.” A realization of the associated risks of “copy and paste” is one first step.