Be careful when employing this commonly-used functionality. While most of us can agree that copy-and-pasting is a blessing, it carries with it a warning. The terminology used for EHR is a language in itself and some phrases are new to clinicians. Staff members should verify a patient’s care information individually to ensure accuracy. The EHR provides information on the overall health of the patient. Whenever you’re dealing with a new condition, treatment, or patient, it’s always best to manually input medical data. The command should be applied for copying demographics, regular patient medications, problem lists, long-standing allergies, and labs.īut appropriate use of the functionality is key. The good news is that there are times when using copy/paste functionality to streamline workflow is appropriate. They’re just trying to ease a workload that has already been besieged by mounting government pressure. By Vera Gruessner MaEHR technology has brought a significant amount of benefits to the healthcare industry from improving data accuracy and patient care to simplifying health. This practice brief identifies best practices to ensure the clinical integrity of EHR systems through appropriate and effective copy functionality practices. In Warner’s judgment, though, most practices are not upcoding their services on purpose. It enables providers to copy health information from a section of a patient's health record to another section or record.
Health IT Safe Practices: Toolkit for the Safe Use of Copy and Paste. AHIMA Position Statement (accessed February 10, 2015) Additional resources: Partnership for Health IT Patient Safety. Warner claimed that inappropriately using copy and paste functions in EHRs has led to medical errors and practices inappropriately billing for services they never provided. American Health Information Management Association: Appropriate Use of the Copy and Paste Functionality in Electronic Health Records. If not caught by the billing department, the procedure could potentially be coded for twice and lead to an overpayment and possible audit in the future.Ĭopy and pasting are of such great concern that Diane Warner, Director of AHIMA, addressed the issue in front of a large crowd at this year’s MGMA. Or let’s say the same ICU unit was to copy a medical procedure from a previous encounter when updating the treatment plan. However, the previous day’s plan may not include the most up-to-date information, and copying over old charts could put the patient at fatal risk if crucial new data is lost during the process. You may have heard of the terms medical record, electronic health record (EHR), and electronic medical record (EMR). Using the previous day’s treatment plan the following day is often routine. Picture an intensive care unit (ICU), where a patient is in a delicate condition and any small change in treatment or medications could affect the outcome of the case. So where does the true danger lie for physicians? Dangers of Copy-and-Pasting in Healthcare Some doctors still view the technique innocuously.
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