The copy/paste feature of your EHR may save time, but you’re walking a thin line by using it. Many physicians feel that the EHR has negatively impacted their productivity, and even reduced the number of patients they can see in a day. So it’s unrealistic to expect time-pressed physicians to abandon copy/paste altogether. Instead, the focus should be on implementing best practices to reduce the errors that all too often accompany the use of this feature.
EHR systems were initially designed to ease the physician’s documentation, but the integrity of patient records is the responsibility of the care provider. “We need to remember at all times that it is our note and its integrity is just as much our responsibility as the care we are rendering to the patient,” emphasized David Silverstone, MD, who spoke to ophthalmologists about EHR compliance and medicolegal issues at AAO 2016 and 2017. Below, a few useful suggestions to ensure the credibility and integrity of their EHR patient records:
- Take your time. “To practice responsible cutting and pasting, slow down,” advises attorney and healthcare compliance expert Michaela D. Poizner. “Double check that the copied text is going into the correct patient’s record, and read the text carefully to make sure that it’s accurate for the particular patient and doesn’t leave out important information.”
- Modify entries to be patient and visit-specific whenever possible. “Cutting and pasting can save time, but it’s often necessary to tweak the copied text,” says Poizner. “Health care organizations need to have a robust policy in place around cutting and pasting with an EHR, including requirements that the provider review and customize copied phrases to accurately reflect each patient and the treatment he or she receives.
- Adjust your mindset to think about each visit as a standalone record. Each standalone record should reflect the level of service delivered for that day and meet reimbursement requirements.
- Pay attention to the alerts, pop-ups, and audit logs in your EHR system. Alert fatigue—when providers get so used to (and annoyed by) the amount of alerts that they just end up tuning the alerts out—is real. But remember, these tools are in place to protect you and your patients. They urge you to reconsider your choices in the EHR.
- Don’t single out physicians. “Make sure staff understand the potential consequences—for the organization and for the individual staff member—of cutting and pasting inappropriately,” says Poizner. “People won’t pay attention to this issue if they don’t realize it’s a big deal,” she adds.