Copy and Paste: The EHR Documentation Gremlin
Laura M. Cascella, MA
The practice of copy and paste — also called cut and paste, cloning, and carrying forward — is one of the most common and problematic documentation issues associated with electronic health records (EHRs). Copy and paste refers to electronically lifting information from a previous entry in a patient’s record and placing it in the current entry. It also refers to copying information from one patient record to paste into another, such as through the use of boilerplate language. Automated functions within EHR systems facilitate copy and paste because of the ease with which users can grab and move content.
A survey done by the Medical Professional Liability Association (formerly PIAA) identifies copy and paste as the leading trend in EHR-related malpractice allegations, and a claims data analysis facilitated by CRICO Strategies also points to copy and paste as a top user error contributing to malpractice lawsuits.1
The allure of copy and paste is easy to understand — in the busy healthcare environment, it offers practitioners a quick, easy, time-saving method for documentation. However, the potential negative consequences of this practice are numerous.
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 decisions are based on erroneous or old information — or if practitioners are so overwhelmed by “note bloat” that they miss critical information.
Second, copy and paste can affect healthcare providers’ credibility, both in litigation and with patients. A patient record that does not accurately portray patient encounters or duplicates erroneous information leads to questions about the basis of clinical judgment and decision-making and the quality of care provided.
Third, the use of copy and paste can have serious corporate compliance implications. When information is carried forward from encounter to encounter without careful review by the healthcare provider, the organization might end up billing for services that did not occur. Even though this type of billing error might be a simple oversight, it could lead to allegations of fraud, which may jeopardize reimbursement from Medicare and other payers.
Finally, copy and paste can have a negative effect on data integrity. One of the overarching goals of EHR systems is to facilitate the electronic exchange of health information and collection and submission of clinical quality measures. Inaccurate data that result from poor practices like copying and pasting may have long-term implications for population health studies, disease tracking, and data mining.3
Strategies for Copy and Paste
Healthcare organizations can address the issue of copy and paste using a variety of risk strategies. For example:
- Work with your EHR vendor to determine whether you can disable your system’s copy and paste function or limit access to specific roles.
- As part of documentation policies, establish guidelines for when copy and paste is prohibited and when it may be used with extreme care.
- In situations in which copy and paste is allowed, ensure that organizational policy stipulates the need for practitioners to carefully review any information carried forward in records.
- Reinforce practitioners’ responsibility for updating/revising copied information as appropriate and electronically signing each record to verify their review and approval of the information.
- Include in documentation policies a requirement that providers note the source of any information they copy and paste in records.
- Encourage providers to revise copy and pasted material to remove redundancy and extraneous details.
- Routinely audit records to check for errors that may have resulted from copying and pasting patient information.
- Educate staff about the dangers and consequences of using poor documentation practices and shortcuts, such as misinformed treatment decisions and fraudulent billing.
For more information about addressing risks associated with the copy and paste function within EHR systems, see ECRI Institute’s Copy/Paste: Prevalence, Problems, and Best Practices and the Partnership for Health IT Patient Safety’s Health IT Safe Practices: Toolkit for the Safe Use of Copy and Paste.
1 PIAA. (2015, January). Part 1 of 2: Electronic health records and a summary analysis on the 2012 PIAA EHR Survey. Research Notes, 1(1), 3; CRICO Strategies. (2017, September 12). CBS educational webinar: EHR-related risks.
2 Frellick, M. (2016, March 16). Note bloat disrupts utility of electronic health records. Medscape. Retrieved from www.medscape.com/viewarticle/860459
3 Dimick, C. (2008, June). Documentation bad habits: Shortcuts in electronic records pose risk. Journal of AHIMA, 79(6), 40–43. Retrieved from http://library.ahima.org/xpedio/groups/public/documents/ahima/ bok1_038463.hcsp?dDocName=bok1_038463
