Assessors conducting peer assessments for the Physician Practice Enhancement Program (PPEP) have seen an increasing number of registrants copying and pasting patient information or patient encounter information into their electronic medical records (EMR) system.
While copy-pasting can improve documentation efficiency, the PPEP advises caution as this approach can lead to inaccurate records and the potential to negatively impact patient care.
Registrants should be aware of the legal implications of copy-pasting and understand the required safeguards to ensure patient confidentiality, privacy, and the requirement for accurate patient data.
Registrants should be aware of:
- Patient privacy and confidentiality: Confidential information may be inadvertently shared during copy-pasting. Care must be taken to ensure that sensitive information is not shared or exposed during the copy-pasting process.
- Data accuracy and integrity: Inaccurate or outdated information perpetuated in the medical record may impact patient care and treatment decisions. Copy-pasting should not replace original content but rather supplement it.
- Documentation duplication: Identical or similar notes across multiple patient records without customization for the individual patient may produce errors. Every patient encounter has its own distinctions and should be checked for accuracy. Conducting audits on encounter notes will improve documentation, detect errors and reduce patient risk.
- Audit trails: Copy-pasting can impact EMR audit trails and make it difficult to trace the origin of specific information.