You are a HIM professional working in Anywhere hospitalàHIM department. You have been asked to review physician documentation within the hospitalànew EHR system, implemented six months ago. The goal of the review is to catch any documentation issues early and work with the appropriate hospital leadership to fix those issues.

As you review the documentation in the EHR, you notice that physicians are utilizing the copy and paste functionality available in the EHR, which allows them to select health record documentation from one source or section of the EHR and replicate it in another source or section of the EHR. In one instance the health record identifies a patient as a 65-year-old male (as identified during the registration process), but in the progress notes the patient is described as a 25-year-old female who has given birth. Clearly, the physician utilized the copy and paste functionality inappropriately and accidentally copied health record information from the health record of a 25-year-old female and pasted that information into the health record of a 65-year-old male.

This type of error could have patient safety concerns, as well as billing and claims issues, and the use of this functionality could open up the facility to potential claims of fraud and abuse by the payer. You take this concern to your leadership and a multidisciplinary group of hospital employees including HIM professionals, nurses, physicians, and billing and revenue cycle employees to discuss and fix the problem. There are mixed opinions about the copy and paste functionality. Some individuals feel this feature is a time-saver and a productivity booster while others believe it only opens the hospital up to additional CMS scrutiny.

1. What should be considered when deciding whether or not to use the copy and paste functionality?

2. What alternatives to the copy and paste functionality are available?