The copy-and-paste function in EHRs may be a time-saver for physicians, but it can have negative consequences for patient care and outcomes and can compromise the integrity of medical records, according to The Joint Commission.
Risks of copying and pasting information in the EHR include copying inaccurate or outdated information, inability to identify the author of the documentation, inability to identify when the documentation was created, inconsistent progress notes and unnecessarily long progress notes.
"The integrity of the patient record and notes in the EHR are of paramount importance as the EHR is becoming the dominant tool for communication between providers, supplanting aspects of verbal communication that assist in medical decision making, clinical follow-up, transitions of care, and medication ordering and dosing," according to the Joint Commission.
Here are four recommendations from The Joint Commission on how to support safe use of the copy-and-paste function in EHRs.
- Identify and balance the risks of copy-and-paste with the potential benefits, and develop training and education surrounding the issue.
- Implement a process that monitors the accuracy of patient records that notifies clinicians when documentation is not accurate.
- Perform ongoing professional performance evaluations with measures related to the record's accuracy.
- Implement a quality review process that evaluates all cases of potential misuse or error due to copy-and-paste functions to identify opportunities for improvement in patient safety.
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