Q&A: Identifying acceptable copy and paste activities in provider documentation

Q: What are some times when it might be acceptable for a provider to copy and paste medical information into an electronic health record (EHR) and when is it absolutely not acceptable?

A: First, obtain and consult the AHIMA copy and paste (copy/paste) practice brief and ACDIS’ position paper, “Electronic health records and the role of the CDI specialist.” Determine how often copy/paste is actually being used. Although people may suspect copy/paste is being used frequently, it is important to have the facts. Conduct a copy/paste audit, or next time there's a coding audit, try to identify when copy/paste is used during encounters. Make a grid and then log these in one admission or outpatient stay, particularly in the progress notes, to see how many times copy/paste occurs.

Once you have that information, go beyond that to see why copy/paste is used and where it came from. Who is the original author? Identify the relevancy. Was this relevant to the case that you have at this time or was it used for other purposes? We know copy/paste is sometimes used as a reminder and as a way to lessen the time it takes clinicians to go back into other documents to find that information. Take those facts, figures, and statistics, and present those back to your department and then the medical staff to show the frequency of copy/paste use and why it is a problem.

In addition, identify why copy/paste is problematic. What are the problems you're seeing? Give real examples. Physicians are more apt to listen when information is presented this way. Their thought process is, “That's a problem? Well prove it to me and show me where it's a problem.” Gather the information about what the problem is that you're seeing and why it particularly affected the particular coding for a case.

Finally, determine the next steps to alleviate usage, or bring the issue up with your medical staff or your medical records committee.

Editor’s Note: Gloryanne Bryant, RHIA, CDIP, CCS, CCDS, a founding ACDIS Advisory Board member, answered this question during the HCPro webinar, “Achieve Compliance Through Ethical Coding Standards.” This article originally appeared in JustCoding.