P&P For cut & paste in EMR

dbutlerdbutler
edited May 2016 in CDI Talk Archive
Does anyone know of policy & procedure related to the cut/copy & paste functions of an EMR?
How these are handled?

and of course be willing to share the P&P?

Thanks,
Don

Donald A. Butler, RN, BSN
Manager, Clinical Documentation
PCMH, Greenville NC
dbutler@pcmh.com

Comments

  • robert.hodges2robert.hodges2
    I work off a Veterans Health Administration directive that states that copy and paste is allowed, but the information copied must be pertinent to the current clinical encounter. Also electronic signatures are never to be copied and pasted into a document as well as the name of a provider who is not directly involved in the care of the patient for that encounter. Copy and paste use is a required monitor in the VA and is also monitored by the Office of the Inspector General. I have to submit a quarterly report on any and all copy and paste violations I may find during my chart reviews.

    Penalties for inappropriate use of copy and paste are also indicated in the directive up to and including violations of federal law. Of course this is for the VA only.

    Robert

    Robert S. Hodges, BSN, MSN, RN, CCDS
    Clinical Documentation Improvement Specialist
    Aleda E. Lutz VAMC
    Mail Code 136
    1500 Weiss Street
    Saginaw MI 48602
  • dbutlerdbutler
    edited May 2016
    Thanks Robert you always have great contributions & offer some good points on details for ideas.

    Does anyone else do as Robert, monitor/audit records for copy & paste appropriateness?

    Don
  • catladyrncatladyrn
    We don't formally audit for copy and paste, but we're supposed to send along any egregious errors, such as "Going for surgery today" when they are POD 7. There may have been some issues regarding physicians copying and pasting notes when they haven't actually seen the patient, but that's not something we can tell from reviewing. Apparently they copy and paste in anticipation of seeing the patient and plan to tack on the current information when they actually round, but that's not ok.

    Renee


    Linda Renee Brown, RN, CCRN, CCDS
    Certified Clinical Documentation Specialist
    Banner Good Samaritan Medical Center
  • robert.hodges2robert.hodges2
    edited May 2016
    As a FYI, Copy and Paste has been identified as a major issue in the VA which is why the OIG is monitoring it and quarterly reports are now required. Per the guidance at least 30 charts in all settings (inpatient and outpatient) must be audited each month. This is now a standard that everyone in the facility involved in record review must report on. It's not easy to catch every time, but there are some clues such as Renee listed, that will make it obvious. I don't know what everyone else's policy is regarding what to do when it's identified, but here a letter is prepared to the provider (or nurse or therapist) that goes through their service chief. It's up to the service chief to take any appropriate action regarding the person who is in violation of the copy and paste policy. We do take it very seriously since old information copied into a new note may not accurately reflect the current condition of the patient and if information is copied into a different patients record it may constitute a HIPAA violation.

    If anyone is interested, you can go to http://www1.va.gov/vhapublications/ViewPublication.asp?pub_ID=1469 for a copy of the policy. Pages 28-29 cover Copy and Paste, "cloned notes", Imported Text, Objects, etc.

    Robert

    Robert S. Hodges, BSN, MSN, RN, CCDS
    Clinical Documentation Improvement Specialist
    Aleda E. Lutz VAMC
    Mail Code 136
    1500 Weiss Street
    Saginaw MI 48602
    P: 989-497-2500 x13101
    F: 989-321-4912
    E: Robert.Hodges2@va.gov
     
    "The difference between the right word and the almost right word is the difference between lightning and the lightning bug." Samuel "Mark Twain" Clemens
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