The Consequences of Inappropriate Usage of the Copy & Paste Function in Electronic Health Records

Posted By ECLAT Health Solutions

Medical coding plays a crucial role in your patients’ health and misuse of the copy and pastes function can cause many consequences. At ECLAT Health Solutions, we provide accurate, efficient, and secure medical coding services. We outsource for hospitals, physician offices, Independent Practice Associations, and a variety of other healthcare providers. Since our coders are all highly trained and experienced, we guarantee a 95% or greater accuracy, so you can be assured your facility is receiving the best quality service.

Below, we discuss the risks of using the copy and paste function:

How Is The Copy & Paste Function Used?

While electronic documentation provides several benefits, such as improved legibility, real-time accessibility, and decreased cost, it can be time-consuming for clinicians. The copy and paste function is always discouraged, as a patient’s documentation should represent any conditions, signs, and symptoms being treated at the time marked by the signature and date. Although, copy and paste provide the ability to re-use all or parts of the information that is provided. This is seen to some as a valuable and time-saving tool. This duplication can be conducted within a single patient’s record or across multiple patient records. Using this function is not a new phenomenon, and it is very common. However, misusing this feature can lead to many consequences.

Consequences of Using the Copy & Paste Function

Copying and pasting medical notes, if done improperly, can lead to numerous unintended consequences. In addition to the consequences listed below, using the copy and paste function may interfere with or compromise communication among the members of the medical care team. It can also interfere with the quality and safety of patient care such as inaccurate or outdated clinical information. Health care providers may also miss important pieces of information due to inaccurate information. This may lead to attempts to inflate, duplicate, or create fraudulent healthcare claims.

• Inaccurate or outdated information
• Repeated information
• Inability to identify the author or intent of documentation
• Inability to identify when the documentation was first created
• Producing false information
• Internally inconsistent progress notes
• Unnecessarily lengthy progress notes

Benefits of Using the Copy & Paste Function

Benefits of using the copy and paste function as necessary include improved efficiency of data capture, timeliness, legibility, consistency, and completeness. Using good judgment while using the copy and paste function enables the creation of better clinical notes to support communication among care providers. Having accurate records will ensure healthy revenue, compliance, and appropriate documentation for payment.

When it comes to mitigating any errors due to the usage of the copy and paste function, AHIMA suggests that: “policies regarding copy-and-paste functionality should be put in place at the institutional level for the management of copied text that balances efficacy with safety. The practice of copy and paste can lead to errors such as inaccurate or outdated information, redundant information (including information not relevant to the patient encounter), inability to identify when the documentation was first created, “note bloat,” and the propagation of false information. Inappropriate use of copy-and-paste can also raise significant patient safety concerns and create risk for the clinician and/or institution. We agree with the draft report that the private sector has led the way in developing best practices for copy and paste functionality and recommend that HHS continue to look to the private sector for solutions that address the appropriate use of copy-and-paste functionality. Along these lines, AHIMA’s ‘Copy Functionality Toolkit’ seeks to assist HIM professionals in ensuring that appropriate organization-wide governance policies and procedures are in place to manage copy and paste functionality including but not limited to: model copy and copy function sanction policies, a model copy functionality audit policy, an education policy for use of copy functionality as well as a provider training checklist and organizational and vendor checklists.”

ECLAT Health Solutions: Professional Medical Coding Services

It is vital to ensure your patients have the most efficient healthcare experience. At ECLAT Health Solutions, we provide medical coding services to ensure your patients’ records are accurate. Our detail-oriented team uses a 3-Tier Quality Assurance process to identify and fix any coding and/or compliance errors to ensure it is accurate every time. We also offer a 24-hour turnaround time to give your facility the accurate coding it needs quickly and efficiently.

Let our medical coding team assist you! Fill out our form to receive more information on our International medical coding services.

Tags: International Coding, Medical Coding, Offshore Coding, copy and paste, electronic health records