Copy/Paste Function in the EHR

Category: Compliance 

Date: September 22, 2016

Reviewed/Revised: 

Purpose

To provide standards for appropriate use of the cloning or copy and paste forward functions within the electronic health record (EHR) for documentation and billing purposes. The EHR is intended to produce an accurate and timely record of the status of the patient, medical decision making, and the outcomes of treatment for each visit. Although the copy and paste function may enhance efficiency, it is vulnerable to intentional or unintentional fraudulent use.

Policy

1. It is the responsibility of the author of a note to review each note and confirm that any copied and pasted data is complete and accurate and that it has been updated to reflect the patient’s status related to the current visit.
2. Medical record information should never be copied and pasted from one patient’s medical record to a different patient’s medical record within any EHR system.
3. Copying and pasting typographical errors should be avoided and each note should be reviewed for such errors before signing.
4. The chief complaint and present symptoms, review of systems, physical examination, and assessment and plan should all be reflective of the patient’s visit on that day. These portions of the note should never be copied forward without appropriate edits.