Strategies to avoid copy-paste abuse

Nov. 19, 2018 / By Sheldon Barlow

With the adoption of Electronic Health Records (EHRs), many healthcare organizations are seeing a dramatic increase in the use of the copy and paste feature. There are numerous tools and helpful applications embedded in EHR systems, which are designed to reduce administrative burden, improve communication and increase the quality of patient care. However, improper use of copy and paste can have medical and legal risks for individual providers and organizations.

Copy and paste abuse by one provider can cloud the judgment of subsequent providers caring for the same patient as inaccurate information may have been copied and pasted into the patient’s record. Also, the improper use of copy and paste can bloat a note with excess and irrelevant information. Here are a few tips for guarding against copy and paste abuse:

  • Establish well defined internal guidelines that outline the proper use of copy and paste within your organization.
  • Ensure that all staff using the EHR receive adequate training each year in proper use of copy and paste.
  • Establish proactive internal audit reviews that focus on copy and paste.
  • When reviewing any medical record, it should be clear what improvements were made from day to day.
  • The exam should not be the same for every patient or for every patient visit.
  • Medical decision making and the assessment or plan should be independent of each subsequent visit.

While there are benefits to using EHR tools like copy and paste, EHR users and healthcare organizations should weigh the pros and cons, outline compliance policies surrounding use of EHR tools, and periodically monitor and review these guidelines to ensure compliance. Federal and state agencies, and commercial insurance companies, are becoming more advanced in applying analytics and other technologies to detect abuse, so proactive and preventive measures are essential. Just like the old saying goes, “Prevention is the best medicine.” 

Sheldon Barlow, MHA, CPC, is an outpatient pro fee consultant at 3M Health Information Systems.

What is the best way to prevent copy-paste errors in documentation?  Check out our infographic for insights.