EHRs offer great promise for improved efficiency but also allow for unacceptable shortcuts. Much has been reported and studied regarding copy-and-paste functions which must be used with caution—the federal government is watching for inappropriate use. 

A December report from the Office of Inspector General (OIG) of the Department of Health and Human Services found, in a survey of 864 hospitals, that only one-fourth had policies governing use of EHR copy-and-paste functions. Only 44 percent had EHR audit logs that record the method of data entry, whether it is copy-and-paste, voice recognition or keyboarding.

The ability to “clone” chart notes from a previous patient encounter to help document the next one can help physicians work more efficiently, but also invite fraud, especially if no one edits the cloned information to make sure it’s accurate and up to date, according to the report.

The Centers for Medicare & Medicaid Services (CMS) are watching EHR documentation. CMS and the Department of Justice issued warning letters to several associations in 2012 regarding the use of EHRs to bill for higher levels of service than what was performed. A physician could bring forward a diagnosis from an earlier visit that no longer applies. In the worst-case scenario, patient information has been copied into another patient’s record.

In response to the OIG report, CMS said it will develop guidelines to ensure that copy-and-paste “is used appropriately.” The organization said it intends to work with the Office of the National Coordinator of Health IT to develop “a comprehensive plan to detect and reduce fraud in EHRs.”

Up to 90 percent of physicians use the copy-and-paste function in their EHR systems, according to a September report from the American Health Information Management Association (AHIMA). Between 20 and 78 percent of physician notes are copied text.

Healthcare delivery organizations need to craft and enforce strict policies regarding the use of this electronic function. To stay off the list of those organizations being monitored for inappropriate documentation, consider the following list of top compliance rules as published in AHIMA’s Copy Functionality Toolkit:

• Use “copy forward” with caution. Cloned documentation is very obvious to auditors.
• Remove irrelevant information from your note.
• Never copy from another provider without clearly identifying the original author.
• Use organization-approved attestations for resident/fellow/mid-level provider notes.
• Authenticate all documentation and orders per policy.
• Never copy the signature block into another note.
• Never copy data or information that identifies a healthcare provider as involved in care he or she is not involved in.
• Do not copy entire lab findings, radiology reports and other information in the record verbatim into a note. Data copied must be specific and pertinent to the care provided.
• Do not reenter previously recorded data.
• Always remember that once you sign your note, you are responsible for its content.

Editor’s note: Copy Functionality Toolkit was published by AHIMA in 2012. All rights reserved.