Many Allied Healthcare Professionals (AHPs) now use electronic medical records to document. This has reduced issues with written documentation, such as orders that cannot be read. Electronic records, however, certainly have their own set of issues in comparison to written records. The inability of systems to communicate/merge information from outpatient to inpatient providers, limited fields for entries, and potential for fields being left incomplete/blank are a few of the challenges in documenting electronically. Another issue that emerges when documenting in electronic records versus written records is “copy and paste.”
We all know there are only so many hours in a day. Insurers seem to require more and more documentation which reduces an AHP’s time in providing patient care. An increase in documentation requirements does not mean, however, that providers can provide less care. As a result, providers may look for ways to cut down on time in documentation.
A 2017 study examined 23,620 notes written by 460 clinicians at the University of California San Francisco Medical Center using an inpatient EHR (Epic). The researchers analyzed inpatient progress notes written by direct care hospitalists, residents, and medical students on a general medicine service for an 8-month time period. The study found that when looking at documentation by residents, medical students, and direct care hospitalists, 18% manually entered text, 46% copied, and 36% imported. In looking at each specifically, residents copied 51.4%, medical students 49.0%, and direct care hospitalists 47.9% of the time. Copying and pasting may seem to solve the issue of time; however, there are risks in this method of documenting.
Certainly, this study highlights that copying and pasting is occurring with some frequency, and although the study is specific to medical providers, copying and pasting is not a practice occurring only with medical providers. Copying and pasting occurs when there are multiple providers involved in a patient’s care and documenting in the same record. A Provider may highlight the text from another provider, such as information from the history and physical, and then carry it forward in his/her note, and the next provider does so as well, and so on. Copying and pasting occurs with all clinicians, including AHPs. Unfortunately, this approach in documenting can give rise to a number of issues.
AHPs who copy and paste rely on another provider’s information/assessment, rather than their own. Errors can occur as individual AHPs may be documenting inaccurate information, such as diagnosis, demographics, impression, etc. The accuracy of these and all elements of information is important when providing adequate patient care. In addition, should an adverse issue occur resulting in a board complaint or lawsuit, the inaccurate information may be highlighted during the matter. It may be challenging for a provider to explain why he/she copied and pasted inaccurate information into a note when he/she should have documented a first-hand account of a patient assessment. An attorney may also encounter challenges when attempting to defend why this was done, and it could potentially impact the defensibility of a board complaint or lawsuit. It is best to document what is seen, observed, and assessed directly versus carrying forward another’s interpretation of how the patient presents.
Before you document in the electronic medical record, keep the following in mind:
- Even if the electronic medical record allows for copying and pasting, it is best not to engage in this practice. It is important that you create your own note. Your assessment should be documented, not someone else’s.
- Copying and pasting may carry forward errors and can increase your risk for liability exposure. Outdated or inaccurate information may be carried forward when engaging in copying and pasting. Keep in mind that a patient’s condition may not be the same as when a provider documented earlier in time.
- Copying and pasting can create long notes and redundancy. Providers may gloss over important information contained within a note.
- Should a board complaint or lawsuit develop, consider how it may impact a case if you carried forward documentation that was not accurate. Always keep in mind how it might appear to a judge or jury if improper information was copied and pasted which negatively impacted patient care.
 Wang, Michael, D., M.D., Khanna, Raman, M.D., and Najafi, Nader, M.D., Characterizing the Source of Text in Electronic Health Record Progress Notes, JAMA Intern Med. 2017;177(8):1212-1213, doi:10.1001/jamainternmed.2017.1548, https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2629493.
Kristen Lambert, JD, MSW, LICSW, CPHRM, FASHRM
Healthcare Practice and Risk Management Innovation Officer
Trust Risk Management Services, Inc.
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