Copy dot in the Technology Assessment

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Aug 6th, 2022
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Using the copy-and-paste function in EHR documentation can make it difficult to determine who originally wrote or contributed to specific sections of the record. This lack of attribution can lead to confusion and potential errors if the information is relied upon for medical decision-making.
AHIMAs position is that copy/paste functionality in EHRs should be permitted only in the presence of strong technical and administrative controls, including policies and procedures, user training and education, and ongoing monitoring.
Technology assessment is the practical process of determining the value of a new or emerging technology in and of itself or against existing or competing technologies, using safety, efficacy, effectiveness, outcome, risk management, strategic, financial, and competitive criteria.
But when it comes to medical notes in patient charts, copying and pasting carries risks of confusion, patient harm, and liability for providers. If the facts that are being pasted are no longer accurate, then providers may be relying on outdated information for diagnoses and treatment plans.
First, although the level of convenience that copy and paste offers is clear, Less clear is the line between efficiency and note quality.2 Copying and pasting content can result in the proliferation of incorrect or nonconsequential information throughout electronic records, which can lead to patient harm if treatment
Proper Use of Copied Information a. Copied information should be brief, selective, and pertinent to the care provided during the current visit. b. Copied text and findings must be integral, relevant and medically necessary to the current encounter.
Copy and paste can promote note bloat, internal inconsistencies, error propagation, and documentation in the wrong patient chart. Existing guidance identified specific responsibilities for authors, organizations, and electronic health record (EHR) developers.

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