Medical Professional Publications

EMR Copy and Paste Policy

(From the March 2017 Issue of MedStat)

Regulatory Corner

The electronic medical record (EMR) provides many advantages over the paper and pen to document our patient care. However, the EMR also presents some challenges. Of these difficulties, the ECRI Institute, an organization focused on the safety in health care, identified the copy and paste issue as particularly problematic stating, “practice is widespread and often underreported and has the potential to cause adverse patient safety events if ‘copy and paste’ practices result in documentation containing inaccurate, irrelevant, or outdated information.” Also, the practice poses potential billing, compliance and malpractice concerns.

To address this problem, a team comprised of practitioners, compliance personnel, information technologists and administrative staff developed a policy on the safe use of the copy and paste function in the EMR and established standards on the use of copied text, dot phrases and smart phrases within the EMR for documentation and billing purposes. The policy applies to all users of the EMR. The details of the policy can be found at:

http://anchor.columbuschildrens.net/webapplications2/DocContent/Documents/Policies/XIII-10_Documentation_Integrity_and_Accuracy_Policy.pdf

A summary of the key points are as follows:

  1. The EMR is the dominant tool for communication between providers, supplanting aspects of verbal communication that assist in medical decision making, clinical follow-up, transitions of care, and medication ordering and dosing.
  2. All users of Nationwide Children’s EMR are responsible for ensuring the integrity, accuracy and necessity of their documentation.
  3. Users are responsible for the total content of their documentation, whether the content is original, copied from elsewhere, or otherwise reused. Users are responsible for correcting any errors identified within the documentation.
  4. The user’s documentation should accurately reflect the patient’s current condition, care and treatment.
  5. Utilizing copy and paste, and copy forward functionalities* is acceptable as long as the result after appropriate note edits and additions is an accurate note.
  6. Copying from one patient chart to another is not permitted except in the following situations:
    1. Note content is legitimately the same for both patients (e.g. shared family history for twins); or
    2. To transfer information from the incorrect record to the correct record.
  7. Users must not copy and paste the information in a manner that could make it appear that the user provided services that he/she did not personally provide.

*See definitions in the policy.

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