MLMIC Risk Management Tip #20 addresses medical professional liability risks related to “Reducing the Risk of the ‘Copy and Paste’ Function in Electronic Health Records.”
The Risk
The “copy and paste” function of electronic health record systems (EHRs) allows users to easily duplicate information such as text, images, and other data within or between documents. While this function offers convenience and efficiency to healthcare providers, it also poses unique liability risks when the information copied and pasted is either inaccurate or outdated. Further, redundancy within the new entry may cause difficulty in identifying current information and may create overly lengthy progress notes.
Recommendations
- Develop a comprehensive policy and procedure for the appropriate use of the copy and paste function. The policy should include a process to monitor and audit both the staffs’ and providers’ use of this function.
- Educate all EHR users about:
- the importance of verifying that the copied and pasted information is correct and accurately describes the patient’s current condition;
- the risks to patient safety in the inappropriate use of this function; and
- the importance of adhering to all regulatory, legal, and compliance guidelines.
- Determine what portions of the record may be copied and pasted. At a minimum, the healthcare provider’s signature(s) should not be copied and pasted.
- Confirm that the source of information which has been copied and pasted can be readily identified and is available for review in the future.
- Confirm that the history of the present illness is based upon the patient’s description during that visit.
- Use the medical, social, or family history from a previous note only after it has been reviewed with the patient to confirm it is current.
- Verify that the diagnoses in your assessment are only those addressed at that visit. Although some EHRs allow the copying of all diagnoses in the problem list, some may either have already been resolved or they are not the reason for this particular encounter.
- Contact your EHR vendor as necessary to help you and your staff comply with established policies. This may include the vendor making modifications which disable the copy and paste function in designated fields, and assisting in performing audits of the use of the copy and paste function by staff and providers.
This MLMIC Risk Management Tip is available here as a PDF: “Reducing the Risk of the ‘Copy and Paste’ Function in Electronic Health Records”
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