Warnings continue to providers to avoid copying and pasting medical record information. It is a common practice, (with 89% of physicians surveyed reported doing it) but may create some real problems later in both the payment for services, and in a risk-related legal process. In the pre-EMR years, a study showed about 9 percent of notes in a chart had copied information and 13% of that copied material was either incorrect or misleading which created greater risk in quality care issues and certainly in legal processes. Expand that to 89% and it is clear that the warning should not be ignored.
Errors are perpetuated, newer information is missed. Many physicians use a template for entering patient information, copying it into the record and then changing the entries for each patient. But if one of those entries is not updated, it can lead to a missed diagnosis.
The time-saving method also raises questions about fraud. Medicare has published they would not pay providers if notes are repeated over a treatment course or are lumped in with other patient information that dealt with similar problems.
Legal sharks have been paying close attention too, carefully going through charts looking for copied material. Since the medical record is a legal document, it will clearly show evidence of copied and pasted material which will not help a provider’s defense in the event of a lawsuit.
New motto: Copy, paste then REVIEW and EDIT then save!