Copying and pasting information within electronic health records can be a risky situation. If you utilize copy and paste, it may be time to consider a quality assurance review process.

Posted in Risk Management on Thursday, September 22, 2016

While copying and pasting in electronic health records (EHRs) may be a means to increased efficiency, is this function ever safe, or can it be made safe?

As a risk manager reviewing medical records, it is easy to spot copied and pasted notes. In fact, copied and pasted notes are an element that risk managers look for during an assessment because it is an element that plaintiff attorneys would be looking for as well.

The risks of copying and pasting information within EHRs include:

• Copying and pasting inaccurate information
• The inability to confirm the author of an entry
• Unnecessarily lengthy notes which can hamper communication
• Raising the question of the legal integrity of the information
• Raising questions of fraud and abuse from Medicare when identical notes are found

With these risks in mind, it is important to not only have policies and procedures regarding the appropriate use of copy and paste, but to also maintain a quality assurance review process (audit process) to monitor if this practice is being done and to what extent. 

Keep in mind that risks usually occur at the point when a practice deviates from its established procedures. Therefore, staff education and training may be necessary to confirm compliance with office policies. 

To help with this, the ECRI Institute’s Partnership for Health IT Patient Safety’s Workgroup created a Toolkit for the Safe Use of Copy and Paste. The toolkit includes information on topics such as risk assessments, sample policy and procedure checklists, training materials and implementation guidelines. This free tool has easy to use and understand material to help you identify, analyze and implement safe copy and paste practices in your office.