Copy/Paste

cspangler4@wellspan.orgcspangler4@wellspan.org
in Clinical & Coding

Hi!

My facility currently utilizes an EHR and as expected, copy/paste with error has become a problem. It is my understanding from the OIG is that copy/paste is not permitted, however I found an article from 2014 AHIMA stating that the use of copy/paste should be permitted only in the presence of strong technical and administrative controls which should include policies/procedures. My facility currently has nothing in place to address copy/paste. I was wondering the stance of other facilities in the ACDIS community. Thanks!

Comments

  • afrady@blr.comafrady@blr.com
    I think you will find the "stance" of other facilities on this varies widely.  Some have almost zero controls on the issue, others have implemented solutions which can detect and flag exact clones with varying degrees of success.  The majority of facilities have written standards which address the problems of cloning and specify what should be in a note, but often you do not see the written policies actually enforced among providers.  The providers themselves also have a wide range of behavior with this from those who are excellent documents to those who are horrible offenders of course.  

    It is more or less the "wild wild west" with this issue out there (as they say).
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