With electronic health records (EHR) rapidly replacing paper records, the use of the copy and paste function in clinical documentation has significantly increased as well. While this practice may have some time-saving benefits, it can also damage the integrity of the patient record.
Inappropriate copy-pasting to patient records can result in HIPAA violations, claim denials, audits and fines, and threats to patient care. The most common risks include:
- Inaccurate or outdated information
- Copying information into the wrong patient file
- Inability to determine exactly when, or the first time, a service was rendered
- Perpetuation of errors
- Inconsistency of documentation
- Unnecessarily lengthy notes containing irrelevant information
EHR-related fraud and abuse
Whether intentional or not, EHR-related fraud is a top concern. The Office of Inspector General (OIG) has for years cautioned that copy-pasting makes it too easy for providers to inflate claims or create false ones. In a report from 2014, the OIG noted that, “...clues within the progress notes, handwriting styles, and other attributes that help corroborate the authenticity of paper medical records are largely absent in EHRs.” The report also addressed overdocumentation and how duplicate and excessive information causes contradictions in records “...suggesting the practitioner performed more comprehensive services than were actually rendered.”1
Patient harm attributed to copy-pasting
A medical record is only useful for clinical decision-making if it’s a trustworthy source. Confusion arises when information is contradictory or hard to find, and this can lead to poor clinical decisions affecting the lives and well-being of patients. Copy-pasting has been identified in the Joint Commission’s sentinel event database as the root cause leading to several reports of patient harm. Examples of documentation errors that have led to harm include outdated weight information used for dose calculation of chemotherapeutic agents and lengthy progress notes that prevented timely and efficient communication.2
Reduce your risk
Healthcare providers must take the proper steps to ensure their records are complete and accurate, containing all the elements essential to creating a narrative for patient care. Records should include documentation that shows the status of patients, their needs at each visit or encounter and the care plans to address those needs. Having policies in place for copy-pasting in the EHR and a process for monitoring records for accuracy may help reduce the risk of liability.
Excelas can quickly and thoroughly review your records to identify errors related to copy-pasting.
In 2017, we reviewed more than 2 million pages of records. Our findings were:
- 90% of the records received were incomplete and gaps in documentation were identified and reported
- 20% were not HIPAA compliant
- 16% contained inconsistent entries with copy-pasting identified as an area of risk
Levinson, Daniel R. CMS and Its Contractors Have Adopted Few Program Integrity Practices to Address Vulnerabilities in EHRs. 2014
“Preventing Copy-and-Paste in EHRs.” Quick Safety, no. 10, Feb. 2015, www.jointcommission.org/assets/1/23/Quick_Safety_Issue_10.pdf.