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Copy, Paste, and Cloned Notes in Electronic Health RecordsImporting Content Into Electronic Health Records: Prevalence, Benefits, Risks, and Best Practice Recommendations FREE TO VIEW

Justin M. Weis, MD; Paul C. Levy, MD
Author and Funding Information

From the University of Rochester Medical Center, Rochester, NY.

Correspondence to: Justin M. Weis, MD, University of Rochester Medical Center, 601 Elmwood Ave, Box 692, Rochester, NY 14642; e-mail: justin_weis@urmc.rochester.edu


For editorial comment see page 444

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2014;145(3):632-638. doi:10.1378/chest.13-0886
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Published online

The modern medical record is not only used by providers to record nuances of patient care, but also is a document that must withstand the scrutiny of insurance payers and legal review. Medical documentation has evolved with the rapid growth in the use of electronic health records (EHRs). The medical software industry has created new tools and more efficient ways to document patient care encounters and record results of diagnostic testing. While these techniques have resulted in efficiencies and improvements in patient care and provider documentation, they have also created a host of new problems, including authorship attribution, data integrity, and regulatory concerns over the accuracy and medical necessity of billed services. Policies to guide provider documentation in EHRs have been developed by institutions and payers with the goal of reducing patient care risks as well as preventing fraud and abuse. In this article, we describe the major content-importing technologies that are commonly used in EHR documentation as well as the benefits and risks associated with their use. We have also reviewed a number of institutional policies and offer some best practice recommendations.

The evolution of electronic health records (EHRs) has created new and varied means of documenting patient care.1 Copy and paste as a technique has been around much longer than computers. The terms were originally coined in reference to the physical process of cutting and pasting paragraphs in different locations during the process of manuscript editing. Now the common keyboard commands for copying text from one source and moving the copied material into the same or an entirely different document have morphed into complex methods of recording patient care information.2 The technologic explosion in the software industry has created a myriad of techniques that function as content importing technology (CIT). In the health-care setting specifically, these documentation tools facilitate importing clinical information into the chart, moving it to other sections within a patient’s record, or even exporting the material for use outside the clinical arena. Templates, macros, automated data points, and copy forward of an entire old note are just a few of the CIT techniques that we will discuss that enable providers to quickly move information throughout a patient’s record and document a clinical encounter. Though these tools offer care providers many new efficiencies as well as opportunities to improve care delivery, they also can be misused or deliberately abused, resulting in the misrepresentation and misattribution of a provider’s effort and guidance of patient care. This is of particular importance in today’s complex care environment, with services provided by many members of a broader care team including nurses; physical, occupational, and respiratory therapists; and home health coordinators, as well as nurse practitioners and/or physician assistants. Since almost all EHR software allows for information to be moved from virtually any part of a patient’s record into another section, these documentation tools create an environment where accurate tracking, attribution of authorship, or both can be lost. Numerous quality-of-care concerns arise, as well as additional risks of malpractice liability and billing fraud and abuse. In academic health centers, these practices could also impact a trainee’s educational experiences and even result in errors in data extraction in medical research.

Advances in computer technology have created multiple ways a provider may copy or generically import information from prior entries of the medical record (Table 1). While it is beyond the scope of this article to address in detail the specific mechanics and functionality of each company’s CIT, we aim to describe in general terms the more common techniques available today. For more information, the reader is referred to specific EHR software companies.

Table Graphic Jump Location
Table 1 —Content Importing Technologies: Functionality

EHR = electronic health record.

The keyboard command Ctrl-C followed by Ctrl-V duplicates highlighted content from almost anywhere in a document or health record, enabling insertion of the copied content into another part of the record. When Ctrl-C/Ctrl-V is used, attribution of the original author and source of the copied material is lost, as is the date and time it was originally created, unless the copied material has this information embedded within it. A macro is a predefined string of text that may be inserted via keystroke or command phrase. Templates are documentation tools that contain predefined text or other options and can be developed for specific types of encounters or medical conditions. Templates can be created with various levels of complexity, including the use of macros, automated data import, data entry fields including check boxes and drop down menus, and place holders for future text entry. Templates may be used to rapidly create a note for a patient encounter with any degree of preset completion. EHRs can also be configured to automatically draw data from other locations in the record and insert it upon specific command. For example, a patient’s vital signs, medications, and allergies can be imported with a key stroke or embedded within a template. These data may automatically update as the EHR updates or with user commands. The term “copy forward” is sometimes applied when copying is applied to a portion or an entire EHR entry. This involves taking a past record entry and duplicating it while updating data fields that are linked within the EHR. There are also versions of copy forward in which a provider may take over entirely the prior user’s note and assume authorship with variable attribution of time, date, and original author of the original source material.

Some EHRs have improved attribution by a facilitated version of copy and paste that tracks information being moved throughout the record. For example, upon importing or pasting information, the EHR will insert author or source information as well as its date and time of origin. This is done using metadata, which is essentially the capability of program software to track users’ activities as they navigate and/or modify a patient’s record. Generation of metadata occurs to a variable degree with each CIT and is often not readily apparent to the average user, being discoverable only by making a more in-depth audit of the electronic record.

EHRs have benefits for patients, physicians, and the broader community.3 Benefit may be realized through improved access to records facilitating communication, increased quality of care through clinical decision support and safety engineering, financial incentives, or potential gains in medical research and education. The benefits specifically attributable to CIT, however, have not been well studied. Even though EHRs have been linked to reductions in productivity, there is a general sense among clinicians that documentation of individual patient encounters is facilitated by using CIT (Table 2). Being able to build the required components of an encounter by importing information from other parts of a patient’s record can save time and potentially eliminate errors introduced by a provider attempting to summarize information obtained from a chart review. Additionally, clinical data entered into specific fields in an encounter template can help with clinical research, allowing for rapid and more sophisticated searches for information, as well as tracking a patient’s clinical course.

Table Graphic Jump Location
Table 2 —Content Importing Technology: Benefits

With the high complexity of patients today, CIT is also credited as helping to track active and inactive (but important) patient problems on an encounter-to-encounter basis whether in the ICU, general hospital floors, or ambulatory arena. At our institution, providers frequently use CIT to bring forward the assessment and plan developed from the patient’s prior encounter or prior hospital day’s visit into the documentation for the current encounter. Operationally, this can be a significant time saver. However, the information must be meticulously reviewed and updated or troublesome documentation errors and patient safety concerns will result.4

Discharge instructions and summaries of a course of care can easily be developed using CIT from previous documentation and data in a patient’s record. Clinical images such as radiology studies or pictures of a patient’s rash or wound can be included in a provider’s note and greatly assist subsequent care by allowing accurate comparisons over time.

The body of literature assessing the prevalence and clinical impact of CIT has been building for > 10 years. An appropriate national conversation regarding its impact has lagged significantly. An in-depth review of 243 patients cared for within the Veterans Administration between 1993 and 2002 found 2,645 notes containing significant amounts of copied text: a 9% prevalence.5 The authors analyzed the type of information copied and the elapsed interval. Each instance was scored using a six-point scale as to how potentially misleading the importing of material appeared and the degree of potential risk from a patient care and safety perspective. A physician with extensive experience in informatics and quality review performed the analysis. Risk was stratified from the lowest, inconsequential level (“Artifact, not misleading, no risk”) through higher levels of concern. Severity levels 5 and 6 were assigned to notes that appeared “misleading, some risk” and “major potential risk of patient harm, fraud or tort claim exposure,” respectively. The authors found 338 instances of copied text with severity levels 5 or 6, thereby deemed to be misleading and creating a significant degree of clinical risk. Of the highest-risk copy events, 47% occurred in the recording of the examination (physical and/or mental), 14% from the history of present illness, and 12% in the past medical history. Only 8% of high-risk copy events included documentation of the provider’s assessment of the patient. The authors also observed that over the last three complete years of the study period of a broader group of patients in the Veterans Administration, the number of copy events nearly tripled.5

A more recent analysis suggests the use of CIT at academic hospitals is even more prevalent.6 A review of 2,068 notes from patients in the ICU who were hospitalized in the fall of 2009 demonstrated that 82% of notes from residents and 74% from attending physicians contained ≥ 20% copied information when analyzing the assessment and plan alone. Although the residents authored more copied notes, the attending physicians copied more content. Extensive use of CIT, however, does not appear unique to the ICU environment. A survey of medicine and pediatrics residents and faculty affiliated with two academic institutions revealed that 89% of the 253 physicians that document electronically made use of CIT.7 Regardless of whether a physician used CIT, the majority recognized that documentation created with these tools was more prone to inconsistency and made it more difficult to identify new information. The physicians surveyed believed that text imported into a patient’s record should be readily identifiable and the EHR software should be designed to alert a provider when notes are too similar. Despite these concerns, the majority of physicians surveyed did not believe that this negatively impacted patient care.

While copy functionality can improve provider efficiency, there are also many potential risks to patient care (Table 3). Risks vary depending on the nature and extent of the copied material.8,9 When the history of present illness or subjective symptoms are copied or imported, there is great concern whether the EHR accurately and succinctly describes the health status of the patient on the date and time of the encounter.10 Importation of allergy and medication lists that have not been reviewed and verified with the patient can perpetuate errors. Macros or templated physical examinations with prepopulated findings raise questions surrounding the accuracy of reported examination findings, as well as concerns as to whether the recorded examination was actually performed. The use of CIT is an even greater quality and safety concern when used in the assessment and plan sections of a patient encounter. For example, patients with multiple medical problems may have complex care plans that are internally inconsistent, inaccurate, and /or outdated.

Table Graphic Jump Location
Table 3 —Content Importing Technologies: Patient Care Risks

Diagnostic and management errors caused by the use of CIT were recently reported.11 A retrospective computer analysis of EHR documentation of primary care patients from a Veterans Affairs facility in 2006 to 2007 used triggers of unplanned care (eg, ED visits, hospital admissions) to determine the reasons behind the patient’s clinical deterioration. The study included 212,165 patient visits and found 190 independent diagnostic errors, including 68 unique missed diagnoses. Review demonstrated 7.4% of index notes related to the diagnostic error were copied and pasted from prior visit notes. Of these cases, the authors concluded that mistakes in copy and pasting contributed to 35.7% of errors.

The trustworthiness of EHRs has also come into question. The indiscriminate use of CIT in a patient’s record can result in unnecessarily lengthy provider documentation that contains redundant or extraneous information. Copying information that is not pertinent to a patient’s visit can lead providers to misinterpret the chronology of a patient’s illness. Inclusion of patient symptoms or problems that were present on admission or a previous care episode can lead to inconsistencies among current reported symptoms, examination findings, and treatment plans. Excessively long documentation can cause “reader fatigue” such that providers will scroll through many pages of redundant documentation and imported reports from laboratory and radiology, increasing the risk that critical new information is overlooked. The sad irony of abusing CIT is that understanding a patient’s clinical course may actually be worsened by the very tools that were expected to improve patient care and safety.12 While not studied or quantified, teaching physicians at our academic medical center have commented that overreliance of providers on CIT does not allow realization of the benefits to patient care derived from the more traditional cognitive exercise of note writing. There is also a sense that the use of CIT inserts diagnostic bias into a clinician’s thinking as a result of seeing prepopulated assessments and plans usurping a clinician’s own experience and reasoning skills.13

Provider use of CIT has raised a number of regulatory concerns associated with hospital and professional billing, as well as reporting of quality data (Table 4).14 The ease in which medical records can be populated with clinical information has caused the Office of the Inspector General to question the medical necessity of the services billed.15,16 For example, excessive documentation for what appears to be a minor clinical problem cannot be used to justify higher levels of hospital or professional billing. Assignment of “present on admission” and “hospital acquired conditions” to a patient’s record could be influenced by indiscriminate use of CIT, resulting in inaccurate assignment of quality metrics. Copying documentation that was originally authored by medical students or other unlicensed professionals could create regulatory risk.17 Medicare has rules limiting or completely disallowing student documentation to be used in support of professional billing for a particular level of service or procedure.

Table Graphic Jump Location
Table 4 —Content Importing Technologies: Regulatory Risks

Abuse of CIT has created a new concern termed “cloned” documentation. Cloned documentation refers to the repetitive pattern of identical or nearly identical notes recorded over the course of an individual patient’s illness or among patients with similar conditions. The efficiencies of cloned documentation when following stable patients with chronic disease are offset by the risks it creates. Providers who copy forward an entire note from a previous visit must remain vigilant by updating the record such that it accurately reflects the patient’s current clinical status and plan of care. Though a specific definition of cloned documentation was not given, Medicare recently issued a warning to providers stating they would deny payment for services, arguing “cloned documentation will be considered a misrepresentation of the medical necessity requirement for coverage of services due to the lack of specific individual information for each unique patient.”18 The Office of the Inspector General, in its 2013 Work Plan, states it will “review multiple [evaluation and management] services for the same providers and beneficiaries to identify [EHR] documentation practices associated with potentially improper payments. Medicare contractors have noted an increased frequency of medical records with identical documentation across services.”19

We reviewed policies and recommendations from several large health-care institutions, the Association of American Medical Colleges, and the American Health Information Management Association with respect to guiding providers in the use of CIT (Table 5). Core themes arose regarding the risks vs benefits of using these tools. Several policies advised against applying CIT to specific subsections of an evaluation and management service. Specifically, the history of present illness and the assessment and plan sections of a note should be documented contemporaneously with the patient’s visit. Copying of documentation by medical students was often specifically prohibited or at least restricted to importing of content as allowed by federal regulations for professional billing. These policies consistently pointed out the need for accurate attribution of source, date, time, and original author of all imported information such that the note accurately represents an individual provider’s effort involved in the management of the patient. Lastly, the Association of American Medical Colleges appropriately emphasizes that “regardless of the tools used to create the note, the individual signing it acknowledges responsibility for the entire content.”20

Table Graphic Jump Location
Table 5 —Policy Reviewa: Selected Do’s and Don’ts of Content Importing Technologies

APP = advanced practice provider; CMS = Centers for Medicare & Medicaid Services; HPI = history of present illness; ROS = review of systems.

a 

All policies mandated final author responsibility for final document, nearly all required documented attribution of copied material.

b 

For example, nurse practitioner, physician’s assistant.

c 

Martha R. Weiner, Senior Director of Billing Compliance and Training, Johns Hopkins University, written communication, 2011.

EHRs are dramatically changing medical documentation. The multitude of methods to import clinical information has created new challenges for clinicians as well as payers. From a patient care perspective, clinicians need to ensure that using CIT enhances not only the documentation of patient care but also the quality of care. While judicious use of CIT can create efficiencies for the busy clinician, as well as improve the tracking of multiple problems on highly complex patients, indiscriminate use of CIT can result in medical records that are not only confusing and inconsistent but result in situations that threaten patient safety.

Unfortunately, clinical documentation is entangled in both professional and hospital reimbursement and has resulted in a “more is better” attitude.31 The payer-required data elements to satisfy evaluation and management, critical care, and various procedure codes are complex, causing physicians to often import large amounts of supporting data as a means of satisfying documentation requirements and safeguarding themselves against fraud and abuse penalties. Similarly, hospitals push providers to comprehensively document the complexities of a patient’s illness to meet coding and reimbursement requirements, and quality metrics. These efforts to quantify a patient’s severity of illness and risk of mortality affect publicly reported hospital rankings and impact reimbursement. It seems very likely that physician use of CIT will only continue to grow given the financial pressures in the health-care environment, unless there is a major reform in payment methodology.

As medical documentation and CIT evolve, health-care system leadership must promote practices that will improve care and support the technology needs of the providers and system. A survey of thought leaders within the US Department of Veterans Affairs describes the greatest future priorities for EHRs as patient centric with cognitive decision support, advancement in information synthesis, support for interdisciplinary teamwork, and greatly improved data management.32 Practice managers and providers need to be aware of the benefits and risks of EHRs, particularly those making use of CIT in their day-to-day practice. Through our review of the technology, including its potential benefits and risks, and a selected overview of institutional policies, we have developed a list of best practices (Tables 6, 7).

Table Graphic Jump Location
Table 6 —Best Practice: Recommended

See Table 1 legend for expansion of abbreviation.

Table Graphic Jump Location
Table 7 —Best Practice: Highest Risk

Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Carter JH. What is the electronic health record?In:Carter JH., ed. Electronic Health Records.2nd ed. Philadelphia, PA: ACP Press; 2008;:3-19.
 
Keyboard shortcuts for Windows. Microsoft website. http://support.microsoft.com/kb/126449. Accessed May 19, 2013.
 
Menachemi N, Collum TH. Benefits and drawbacks of electronic health record systems. Risk Manag Healthc Policy. 2011;4:47-55. [CrossRef] [PubMed]
 
Weir CR, Hurdle JF, Felgar MA, Hoffman JM, Roth B, Nebeker JR. Direct text entry in electronic progress notes. An evaluation of input errors. Methods Inf Med. 2003;42(1):61-67. [PubMed]
 
Hammond KW, Helbig ST, Benson CC, Brathwaite-Sketoe BM. Are electronic medical records trustworthy? Observations on copying, pasting and duplication. AMIA Annu Symp Proc. 2003;2003:269-273.
 
Thornton JD, Schold JD, Venkateshaiah L, Lander B. Prevalence of copied information by attendings and residents in critical care progress notes. Crit Care Med. 2013;41(2):382-388. [CrossRef] [PubMed]
 
O’Donnell HC, Kaushal R, Barrón Y, Callahan MA, Adelman RD, Siegler EL. Physicians’ attitudes towards copy and pasting in electronic note writing. J Gen Intern Med. 2009;24(1):63-68. [CrossRef] [PubMed]
 
Erickson DR. Paradoxical consequences and electronic notes. J Urol. 2013;189(3):793-795. [CrossRef] [PubMed]
 
Hirschtick RE. A piece of my mind. John Lennon’s elbow. JAMA. 2012;308(5):463-464. [CrossRef] [PubMed]
 
Embi PJ, Yackel TR, Logan JR, Bowen JL, Cooney TG, Gorman PN. Impacts of computerized physician documentation in a teaching hospital: perceptions of faculty and resident physicians. J Am Med Inform Assoc. 2004;11(4):300-309. [CrossRef] [PubMed]
 
Singh H, Giardina TD, Meyer AND, Forjuoh SN, Reis MD, Thomas EJ. Types and origins of diagnostic errors in primary care settings. JAMA Intern Med. 2013;173(6):418-425. [CrossRef] [PubMed]
 
Schiff GD, Bates DW. Can electronic clinical documentation help prevent diagnostic errors? N Engl J Med. 2010;362(12):1066-1069. [CrossRef] [PubMed]
 
Horsky J, Zhang J, Patel VL. To err is not entirely human: complex technology and user cognition. J Biomed Inform. 2005;38(4):264-266. [CrossRef] [PubMed]
 
AHIMA’s e-HIM work group. Guidelines for EHR documentation to prevent fraud. J AHIMA. 2007;78(1):65-68.
 
Health and Human Services and Department of Justice letter to health associations. Kaiser Health News website. http://capsules.kaiserhealthnews.org/wp-content/uploads/2012/09/HHS-DOJ-Letter-to-Health-Associations.pdf. Accessed February 20, 2013.
 
Early assessment finds that CMS faces obstacles in overseeing the Medicare EHR Incentive Program. Report (OEI-05-11-00250) 11-28-2012. Department of Health and Human Services website. https://oig.hhs.gov/oei/reports/oei-05-11-00250.asp. Accessed February 17, 2013.
 
Compliance Advisory 3: a challenge for the electronic health records of academic institutions: physicians combining documentation or using information documented by others when billing for a professional service. Association of American Medical Colleges website. https://www.aamc.org/download/316610/data/advisory3achallengefortheelectronichealthrecordsofacademicinsti. Accessed February 17, 2013.
 
Cloned documentation could result in Medicare denials for payment. National Governmental Services website. http://bit.ly/18C09ky. Published September 12, 2009. Accessed July 12, 2013.
 
HHS OIG work plan. FY 2013. Part I: Medicare Part A and Part B, page 25. Department of Health and Human Services website. https://oig.hhs.gov/reports-and-publications/archives/workplan/2013/Work-Plan-2013.pdf. Accessed March 29, 2013.
 
Gelzer R, Hall T, Liette E, Warner D, Wiedemann LA. Copy Functionality Toolkit: A Practical Guide: Information Management and Governance of Copy Functions in Electronic Health Record Systems. Chicago, IL: AHIMA Press; 2012.
 
Compliance Officers Forum AAMC. Electronic health records in academic medical centers compliance advisory 2: appropriate documentation in an EHR: use of information that is not generated during the encounter for which the claim is submitted: copying/importing/scripts/templates. American Association of Medical Colleges website. https://www.aamc.org/download/253812/data/appropriatedocumentationinanehr.pdf. Published July 11, 2011. Accessed March 28, 2013.
 
Steigewald C. Banner Health POLICY and PROCEDURE HIMS: medical record documentation. Number 678.5 9/9/2011. Banner Health website. https://www.bannerhealth.com/NR/rdonlyres/1C7C6A54-E015-4B24-8064-B70C503ED185/62222/MedicalRecordDocumentation6785.pdf. Accessed March 28, 2013.
 
Johnson ML. Electronic EHR cloning (copy & paste) functions. Texas Tech University Health Sciences Center Billing Compliance Program and Policy and Procedure. Texas Tech University Health Sciences Center website. http://www.ttuhsc.edu/billingcompliance/documents/BCP_7.2_Clone_071510.pdf. Published July 15, 2010. Accessed February 25, 2013.
 
Forrest S, Naughton K. “Copy/paste” guidelines: guidance for appropriate use of electronic medical record (EMR) functions” UC San Diego Health System Compliance Program. University of San Diego Health System website. http://healthsciences.ucsd.edu/compliance/billing-compliance/Documents/3-Guidance_Copy%20Paste%20Function%20and%20EMR_Final%2001092012.pdf. Published January 30, 2012. Accessed March 29, 2013.
 
College of Medicine Office of Compliance. Compliance tip. University of Florida College of Medicine website. www.med.ufl.edu/complian/q&a/epic_do_and_donts.html. Accessed February 25, 2012.
 
Sarne D. University of Illinois Medical Center at Chicago documentation guideline: copy and paste function in the electronic medical record No G-4. University of Illinois at Chicago website. http://chicago.medicine.uic.edu/UserFiles/Servers/Server_442934/File/Compliance/G-4.4%20Copy%20and%20Paste%20Function%20in%20the%20Electronic%20Medical%20Record.pdf. Published April 4, 2006. Accessed March 28, 2013.
 
Compliance policy and procedure: electronic medical records policy number: C-009. University of Washington website. http://psychres.washington.edu/clinicaltools/electronic_record.pdf. Published March 11, 2010. Accessed March 29, 2013.
 
Gleadall T. Could you be accused of cloning. Compliance Compass. Vanderbilt University Medical Center website. http://www.mc.vanderbilt.edu/documents/DCCI/files/July%202012%20Edition%20%20-%20Final.pdf. July 2012. Accessed March 29, 2013.
 
Washington University Physicians. Washington University School of Medicine in St. Louis. EMR – data replication policy. Washington University School of Medicine website. https://fpp.wusm.wustl.edu/fpppolicies/Pages/EMR-DataReplicationPolicy.aspx. Published October 13, 2009. Accessed March 29, 2013.
 
West Virginia University Physicians of Charleston. Policies and procedures: copy and paste functionality in electronic documentation. Policy/Procedure No: B-28. West Virginia University Physicians of Charleston website. http://www.wvupc.org/compliance/PDF/Policy%20re%20Copy%20and%20Paste%20Functionality%20within%20Epic.pdf. Published August 23, 2012. Accessed March 28, 2013.
 
Berenson RA, Basch P, Sussex A. Revisiting E&M visit guidelines—a missing piece of payment reform. N Engl J Med. 2011;364(20):1892-1895. [CrossRef] [PubMed]
 
Saleem JJ, Flanagan ME, Wilck NR, Demetriades J, Doebbeling BN. The next-generation electronic health record: perspectives of key leaders from the US Department of Veterans Affairs. J Am Med Inform Assoc. 2013;20(e1):e175-e177. [CrossRef] [PubMed]
 

Figures

Tables

Table Graphic Jump Location
Table 1 —Content Importing Technologies: Functionality

EHR = electronic health record.

Table Graphic Jump Location
Table 2 —Content Importing Technology: Benefits
Table Graphic Jump Location
Table 3 —Content Importing Technologies: Patient Care Risks
Table Graphic Jump Location
Table 4 —Content Importing Technologies: Regulatory Risks
Table Graphic Jump Location
Table 5 —Policy Reviewa: Selected Do’s and Don’ts of Content Importing Technologies

APP = advanced practice provider; CMS = Centers for Medicare & Medicaid Services; HPI = history of present illness; ROS = review of systems.

a 

All policies mandated final author responsibility for final document, nearly all required documented attribution of copied material.

b 

For example, nurse practitioner, physician’s assistant.

c 

Martha R. Weiner, Senior Director of Billing Compliance and Training, Johns Hopkins University, written communication, 2011.

Table Graphic Jump Location
Table 6 —Best Practice: Recommended

See Table 1 legend for expansion of abbreviation.

Table Graphic Jump Location
Table 7 —Best Practice: Highest Risk

References

Carter JH. What is the electronic health record?In:Carter JH., ed. Electronic Health Records.2nd ed. Philadelphia, PA: ACP Press; 2008;:3-19.
 
Keyboard shortcuts for Windows. Microsoft website. http://support.microsoft.com/kb/126449. Accessed May 19, 2013.
 
Menachemi N, Collum TH. Benefits and drawbacks of electronic health record systems. Risk Manag Healthc Policy. 2011;4:47-55. [CrossRef] [PubMed]
 
Weir CR, Hurdle JF, Felgar MA, Hoffman JM, Roth B, Nebeker JR. Direct text entry in electronic progress notes. An evaluation of input errors. Methods Inf Med. 2003;42(1):61-67. [PubMed]
 
Hammond KW, Helbig ST, Benson CC, Brathwaite-Sketoe BM. Are electronic medical records trustworthy? Observations on copying, pasting and duplication. AMIA Annu Symp Proc. 2003;2003:269-273.
 
Thornton JD, Schold JD, Venkateshaiah L, Lander B. Prevalence of copied information by attendings and residents in critical care progress notes. Crit Care Med. 2013;41(2):382-388. [CrossRef] [PubMed]
 
O’Donnell HC, Kaushal R, Barrón Y, Callahan MA, Adelman RD, Siegler EL. Physicians’ attitudes towards copy and pasting in electronic note writing. J Gen Intern Med. 2009;24(1):63-68. [CrossRef] [PubMed]
 
Erickson DR. Paradoxical consequences and electronic notes. J Urol. 2013;189(3):793-795. [CrossRef] [PubMed]
 
Hirschtick RE. A piece of my mind. John Lennon’s elbow. JAMA. 2012;308(5):463-464. [CrossRef] [PubMed]
 
Embi PJ, Yackel TR, Logan JR, Bowen JL, Cooney TG, Gorman PN. Impacts of computerized physician documentation in a teaching hospital: perceptions of faculty and resident physicians. J Am Med Inform Assoc. 2004;11(4):300-309. [CrossRef] [PubMed]
 
Singh H, Giardina TD, Meyer AND, Forjuoh SN, Reis MD, Thomas EJ. Types and origins of diagnostic errors in primary care settings. JAMA Intern Med. 2013;173(6):418-425. [CrossRef] [PubMed]
 
Schiff GD, Bates DW. Can electronic clinical documentation help prevent diagnostic errors? N Engl J Med. 2010;362(12):1066-1069. [CrossRef] [PubMed]
 
Horsky J, Zhang J, Patel VL. To err is not entirely human: complex technology and user cognition. J Biomed Inform. 2005;38(4):264-266. [CrossRef] [PubMed]
 
AHIMA’s e-HIM work group. Guidelines for EHR documentation to prevent fraud. J AHIMA. 2007;78(1):65-68.
 
Health and Human Services and Department of Justice letter to health associations. Kaiser Health News website. http://capsules.kaiserhealthnews.org/wp-content/uploads/2012/09/HHS-DOJ-Letter-to-Health-Associations.pdf. Accessed February 20, 2013.
 
Early assessment finds that CMS faces obstacles in overseeing the Medicare EHR Incentive Program. Report (OEI-05-11-00250) 11-28-2012. Department of Health and Human Services website. https://oig.hhs.gov/oei/reports/oei-05-11-00250.asp. Accessed February 17, 2013.
 
Compliance Advisory 3: a challenge for the electronic health records of academic institutions: physicians combining documentation or using information documented by others when billing for a professional service. Association of American Medical Colleges website. https://www.aamc.org/download/316610/data/advisory3achallengefortheelectronichealthrecordsofacademicinsti. Accessed February 17, 2013.
 
Cloned documentation could result in Medicare denials for payment. National Governmental Services website. http://bit.ly/18C09ky. Published September 12, 2009. Accessed July 12, 2013.
 
HHS OIG work plan. FY 2013. Part I: Medicare Part A and Part B, page 25. Department of Health and Human Services website. https://oig.hhs.gov/reports-and-publications/archives/workplan/2013/Work-Plan-2013.pdf. Accessed March 29, 2013.
 
Gelzer R, Hall T, Liette E, Warner D, Wiedemann LA. Copy Functionality Toolkit: A Practical Guide: Information Management and Governance of Copy Functions in Electronic Health Record Systems. Chicago, IL: AHIMA Press; 2012.
 
Compliance Officers Forum AAMC. Electronic health records in academic medical centers compliance advisory 2: appropriate documentation in an EHR: use of information that is not generated during the encounter for which the claim is submitted: copying/importing/scripts/templates. American Association of Medical Colleges website. https://www.aamc.org/download/253812/data/appropriatedocumentationinanehr.pdf. Published July 11, 2011. Accessed March 28, 2013.
 
Steigewald C. Banner Health POLICY and PROCEDURE HIMS: medical record documentation. Number 678.5 9/9/2011. Banner Health website. https://www.bannerhealth.com/NR/rdonlyres/1C7C6A54-E015-4B24-8064-B70C503ED185/62222/MedicalRecordDocumentation6785.pdf. Accessed March 28, 2013.
 
Johnson ML. Electronic EHR cloning (copy & paste) functions. Texas Tech University Health Sciences Center Billing Compliance Program and Policy and Procedure. Texas Tech University Health Sciences Center website. http://www.ttuhsc.edu/billingcompliance/documents/BCP_7.2_Clone_071510.pdf. Published July 15, 2010. Accessed February 25, 2013.
 
Forrest S, Naughton K. “Copy/paste” guidelines: guidance for appropriate use of electronic medical record (EMR) functions” UC San Diego Health System Compliance Program. University of San Diego Health System website. http://healthsciences.ucsd.edu/compliance/billing-compliance/Documents/3-Guidance_Copy%20Paste%20Function%20and%20EMR_Final%2001092012.pdf. Published January 30, 2012. Accessed March 29, 2013.
 
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Sarne D. University of Illinois Medical Center at Chicago documentation guideline: copy and paste function in the electronic medical record No G-4. University of Illinois at Chicago website. http://chicago.medicine.uic.edu/UserFiles/Servers/Server_442934/File/Compliance/G-4.4%20Copy%20and%20Paste%20Function%20in%20the%20Electronic%20Medical%20Record.pdf. Published April 4, 2006. Accessed March 28, 2013.
 
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Gleadall T. Could you be accused of cloning. Compliance Compass. Vanderbilt University Medical Center website. http://www.mc.vanderbilt.edu/documents/DCCI/files/July%202012%20Edition%20%20-%20Final.pdf. July 2012. Accessed March 29, 2013.
 
Washington University Physicians. Washington University School of Medicine in St. Louis. EMR – data replication policy. Washington University School of Medicine website. https://fpp.wusm.wustl.edu/fpppolicies/Pages/EMR-DataReplicationPolicy.aspx. Published October 13, 2009. Accessed March 29, 2013.
 
West Virginia University Physicians of Charleston. Policies and procedures: copy and paste functionality in electronic documentation. Policy/Procedure No: B-28. West Virginia University Physicians of Charleston website. http://www.wvupc.org/compliance/PDF/Policy%20re%20Copy%20and%20Paste%20Functionality%20within%20Epic.pdf. Published August 23, 2012. Accessed March 28, 2013.
 
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Saleem JJ, Flanagan ME, Wilck NR, Demetriades J, Doebbeling BN. The next-generation electronic health record: perspectives of key leaders from the US Department of Veterans Affairs. J Am Med Inform Assoc. 2013;20(e1):e175-e177. [CrossRef] [PubMed]
 
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