Q&A: Querying a provider about copying and pasting in the EHR
Q: Ever since we moved to an electronic health record (EHR), our HIM department has noticed some physicians copying and pasting information from previous records. How do we know when this is allowed or when we can query the provider to clarify?
A: Copying and pasting of documentation has become a commonplace problem with the advent of the EHR. According to a 2013 article in the journal Critical Care Medicine, 82% of all residents’ and 74% of all attending physicians’ notes contained greater than or equal to 20% copied information. Many physicians, for example, will copy and paste the same progress note from the previous day, even though it might contain important documentation elements, such
as vital signs. EHRs often promote copy and paste functionality as a time saver, but in reality, copy/paste, used inappropriately, can lead to denials and/or allegations of fraud.
If documentation, whether lab results or information in the progress notes, is simply pasted into the medical record without any explanation, a query should be posed to clarify. Different organizations interpret this practice differently. Coders can ask their coding supervisor or manager to better understand their organization’s policies around the copy-and-paste functionality. Consistency within the organization is important, and the coding team should be aware of any such policies to communicate those back out to the medical staff during regular, ongoing education.
Editor’s note: This question was adapted from the HCPro book The Coder's Guide to Physician Queries by Adrienne Commeree, CPC, CPMA, CCS, CEMC, CPIP, with contributions from Rose T. Dunn, MBA, RHIA, CPA, CHPS, FACHE.