Is copy and paste an acceptable form of patient care documentation?
Using the copy and paste function with electronic medical records is a questionable ethical and legal manner in which to document patient care. Cloned documentation is often done when trying to save time and/or when the patient has not been fully assessed, leading to errors continuously being forwarded in a patients
Can you copy and paste in medical records?
Clinical providers are permitted to use the copy and paste functionality when documenting within electronic medical record systems for the purpose of patient care. Clinical providers are responsible for the total content of their documentation, whether the content is original, copied, pasted, or reused.
What is copy and paste in medical records?
Pasting - Placing information copied or cut from one document into another document. Copy/Forward Copying a docHub section or an entire prior note which is then edited and updated. Page 2. Page 2 of 3. Cloning - Copying material from a prior note and placing it into a current record without review and updating.
What is the argument against the use of copy and paste function in the EHR?
The use of copy and paste in medical documentation raises many concerns. As in the case discussed by Hirschtick, the use of copy and paste may contribute to the introduction of inaccurate information within patients records and cloud the judgment of subsequent providers.
Why is copying and pasting in the medical record potentially concerning?
Issue: The use of the copy-and-paste function (CPF) in health care providers clinical documentation improves efficiencies, however CPF can promote note bloat, internal inconsistencies, error propagation, and documentation in the wrong patient chart,1 potentially putting patients at risk.
Why should you not copy and paste in EHR?
Issue: The use of the copy-and-paste function (CPF) in health care providers clinical documentation improves efficiencies, however CPF can promote note bloat, internal inconsistencies, error propagation, and documentation in the wrong patient chart,1 potentially putting patients at risk.
What is copy and paste in medical records?
Pasting - Placing information copied or cut from one document into another document. Copy/Forward Copying a docHub section or an entire prior note which is then edited and updated. Page 2. Page 2 of 3. Cloning - Copying material from a prior note and placing it into a current record without review and updating.
Should copy and Paste be allowed in an EHR?
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.
Can you copy and paste in medical records?
Clinical providers are permitted to use the copy and paste functionality when documenting within electronic medical record systems for the purpose of patient care. Clinical providers are responsible for the total content of their documentation, whether the content is original, copied, pasted, or reused.
What is copy and paste in EHR?
The copy and paste function provides the ability to re-use all or parts of detailed narrative information and is seen by physicians and EHR system users as a valuable and time saving tool. 9. This duplication of notes can be conducted within a single patients record or across multiple patients records.