The Dangers of Copy And Pasting Documentation

There are a lot of Copy and Paste horror stories. Physicians who accidentally copy and pasted information from one patient’s record to a different patient. Or Copy and Pasting that goes rogue and suddenly, a woman with a family history of breast cancer has a history of breast cancer herself.

Copy and pasting (or cloning, or pulling forward) information from past visits is meant to save time but can result in risks to your practice.

If payers notice redundant documentation they may question the accuracy and the amount of work that was done from one visit to the next. To that end, the use of Copy and Paste has the potential to put your organization at risk of pre-payment audits.

That’s why it’s important to weigh the benefits and learn how to minimize errors before your practice takes advantage of shortcuts. There are a number of appropriate ways to use the copy/paste tools. It can be used to copy a patient’s regular medications, long standing allergies, demographics, problem list and labs and treatments if they're ongoing. Being careful is key and this is why it’s so important to educate your staff.

Tune in to our upcoming webinar, “Cloning, and Copy & Paste, and Pull Forward, Oh My!,” to learn how to preserve and protect the integrity of your medical records and learn proper terminology associated with shortcuts, risks and benefits of automation in the EHR, and strategies for safely using tools.