Policy or written guidelines for handlilng cloed or cut/paste notes

sbeattysbeatty
in CDI Talk Archive
I am working with physicians in our organizaton to develop guidelines regarding the use of the cut & paste function in generation of a note or other official document in the electronic medical record. Does anyone have anything they would be willing to share? If not, can you refer me to anyone who might be able to provide input or provide an example or draft? We have the AHIMA papers regarding this issue but no thers references. Thanks in advance!!

Comments

  • angelisa.romanelloangelisa.romanello
    edited May 2016
    I believe the best guidelines are ,"do not cut and paste." Each note needs to stand on its own.
    Lisa

    Lisa Romanello,RN,BSN,FNS,CCDS
    Manager, Clinical Documentation Improvement Specialist
    CJW Medical Center
    Quality and Compliance
    804-228-6527



  • sharon.colesharon.cole
    edited May 2016
    I know our nursing staff had to stop doing this after a JCAHO survey so you may look there for guidance. We've not had any luck with getting the copy and paste to stop by physicians and no one but me and medical records tried to change/address the behavior. So now, I'm just waiting for the next JCAHO survey - the hospital will certainly have to listen when they get "dinged" - I hope. If you figure out something that works, please share. I'm sure there are several facilities who would benefit!

    Sharon Cole, RN, CCDS
    CDI Specialist
    254.751.4256
    Sharon.cole@phn-waco.org

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