Tips to Avoid Trouble with Copying EHR Documentation

By Lisa Eramo  |  November 7, 2016

Being able to copy and paste information in the EHR saves time and improves efficiency. But when physicians use the functionality inappropriately, it can also cause significant patient safety issues.

Robert Giannini, NHA, CHTS-IM/CP and Lorraine Possanza, DPM, JD, MBE, of the ECRI Institute, talked about some of these issues and how to mitigate risk during a presentation at the 88th annual American Health Information Management Association’s (AHIMA) annual convention held October 16-19 in Baltimore, MD. The ECRI Institute is a nonprofit organization that applies scientific research to improve patient care and safety.

“Electronic health records aren’t really the cause [of safety issues]—but they do play a role. It’s important to keep that in mind and to be cautiously aware of what’s going on,” said Possanza.

Much of the problem stems from an over-reliance on EHR automation and shortcuts, said Giannini. He reminded attendees that these shortcuts come in many forms, each of which require user validation. Examples of these shortcuts include the following:

  • Selecting data from an original source and reproducing it in another location either by keyboard (Ctrl + C to copy and Ctrl + V to paste) or with a mouse
  • Duplicating a note (i.e., cloning)
  • Bringing forward a portion of a previous note or the entire note
  • Automatically drawing data from another part of the record and inserting it using a specific command (i.e., autofill)
  • Automatically populating text in each record (i.e., autocompletion)

When physicians copy and paste information frequently, they run the risk of jeopardizing the integrity of the information, said Possanza. “Is that information timely, accurate, and contemporary? It may not be,” she added.

Documentation that is copied and pasted can also lead to an over-abundance of information in the medical record. Physicians may inadvertently overlook important data. Unfortunately, this can lead to diagnostic error, said Giannini.

“The note becomes so big, long, and convoluted that you really can’t tell the true picture of what’s going on with the patient,” he added.

The ECRI Institute’s Copy and Paste Toolkit, a free resource, includes several examples of how physicians use copy and paste functionality incorrectly. Following are a few of them:

  • A physician copies and pastes admissions information, imaging study reports, and labs from a previous day’s notes into current-day progress notes, making the notes difficult to follow and interpret.
  • Communication by email in the patient portal includes information pasted from another patient’s chart.
  • Vital signs are copied and pasted from previous visits into the current-day history and physical exams.
  • Lab information is identified and copied but pasted into the incorrect chart.

Copy and paste compliance: 4 tips
​Possanza and Giannini provided these tips to help practices ensure compliance when using copy and paste functionality in the EHR.

  1. Work with your EHR vendor to ensure that copy and paste information is easily identifiable. This ensures that information can be verified for accuracy, and it facilitates review for edits.
  2. Ensure that you can trace the provenance of copied and pasted material. This allows practices to verify that the information is appropriate and accurate, and it may also increase the potential to defend the record and achieve billing compliance.
  3. Ensure adequate staff training and education regarding the appropriate and safe use of copy and paste functionality. Focus on the benefits as well as the potential patient safety risks from improper use.
  4. Monitor, measure, and assess copy and paste practices regularly. This ensures the integrity of the clinical record, the quality and safety of care rendered, and compliance with state and federal regulations.

Watch for more recaps from AHIMA on Go Practice this month.


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