American Health Information Management Association (AHIMA) published a report that said 80%-90% of physicians use the function of copy & paste, while 20%-78% create notes from copied texts. It is not a surprise that physicians are making lot of mistakes while making notes in their Electronic Health Records (EHR) because of this practice.
Risks of copy & pasting in EHR
Physicians usually copy/paste the previous visit’s treatment plan as a follow-up. This may be dangerous to the patient’s condition in an intensive care unit (ICU), where minor incorrect information may cost their life.
Copying previous data in a hurry will put the patient in fatal risk, as the charts are not up-to-date with new details of the patient’s condition.
This is not only a risk for the patient, but may also be problematic for your Revenue Cycle. Let’s say physician copies patient clinical details from previous visit in the new chart and sends the details to billing department. The billing staff may create a duplicate claim, which is going to be declined by the insurance provider. In case if the claim is processed, then the physician will have to bear penalty during the audit.
Copy and paste issue in Electronic Health Records (EHRs) is a huge concern among healthcare professionals. Director of AHIMA, Diane Warner highlighted this issue while speaking at the MGMA event in 2013. Warner said that large number of medical errors had been the result of copy/paste function in EHRs. Also, physicians would bill inappropriately for the services they never provided.
She added that most of the physicians are using this function without the purpose of committing fraud by duplicate billing, but their unawareness has landed them in great troubles.
However, copy/paste is not a risk in every template. Physicians can use this function to copy demographics, some long standing histories and allergies, and regular medications.
But the best practice of data recording is to take down information on every visit of the patient, or inquire if there has been any change in previous demographic details of the patients. This way, the physician will avoid the possibility of any fatal mishap or audit fraud.