Dear Nancy,
At work, I have started to see copy and paste documentation in the home health record for patient instruction. Is this an acceptable form of documentation for home health nursing visits?
Carl
Dear Carl,
Using the copy and paste function with electronic medical records is a questionable ethical and legal manner in which to document patient care. ”Cloned” documentation is often done when trying to save time and/or when the patient has not been fully assessed, leading to errors continuously being forwarded in a patient’s record. Those errors can lead to improper care or a wrong diagnosis.
Although it is not know how many nurses use this function, many probably do. According to an article by American Sentinel University, a recent American Health Information Management Association report indicates between 20% and 78% of physicians’ notes contain copied text.
The same article discussed a report of the Office of Inspector General finding that only 25% of hospitals surveyed had policies regarding the use of the copy and paste function in their EMRs.
Remember that as a licensed nurse, you are responsible for the care you provide and for the accurate and complete documentation of that care, regardless of whether it is in a handwritten format or in the EMR. This responsibility means you never use outdated data over and over again to save time. Nor do you note bloat, copying and pasting of a previous patient evaluation as a current notation containing meaningless information about the patient, for the current date. Nor do you copy and paste another patient’s documented nursing entry into your patient’s EMR as your notation.
Remember, too, that the falsification of any record made in the course of your practice of nursing, including patient care records, can result in the state board of nursing initiating a professional discipline case against you. An allegation of unprofessional conduct could also occur.
According to the article cited above, the copy and paste function can be useful to record a patient’s address or record patient allergies with an attribution that the information was copied from another source. But for responsible, ethical and legal patient care documentation, the function should be used judiciously and in accordance with your healthcare entity’s policy concerning its use.
Regards, Nancy
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I work in an ICU where we generally do vital signs every hour and head-to-toe patient assessments every 4 hours. Our electronic charts are equipped with the “copy from previous assessment” function. I find this function incredibly useful but also acknowledge that it can lead to inaccurate documentation at times. To give some positive examples, on the vital sign flowsheet, we document what heart rhythm the patient is in. Not always, but most of the time, the rhythm does not change. This means that the copy and paste function has saved me some steps by allowing me to skip selecting the rhythm from the dropdown menu. The same can be said for the method and location of blood pressure assessment. If the cuff is on the left upper arm, it usually stays there. I feel that so long as the nurse is ensuring that the data they are charting is accurate, it shouldn’t matter if they used the copy & paste function or if they manually entered each piece of data one by one. I think that one of the EMR’s benefits is the time saved by documenting with copy & paste. As always, the nurse must ensure accuracy of data, and as long as it is accurate, then there is no problem in my eyes,
I’ve recently found where a nurse has copy and pasted my ducumentation and used it as her own, word for word information. My company is acting like this nurse did nothing wrong when she used my exact words and my observations, not hers. I would like some advice on what I should do about this.
I have been researching this for a couple of weeks. Without written guide lines many managers will see the issue from one end of the spectrum to the other. I know a elderly nurse with a twisted up spine that had her world turned upside down for using copy paste. She was shown how to do this when she sat in the epic class. She used it only in the unchanged sections of assessment and put in the changes manually. Copy past is used by many in this hospital, both nurses and doctors. Her manager said it is falsifying or fraud documents. The only written policy the nuse could find was telling doctors to be cautious when using copy past. Documents i have read makes me believe copy past used this particular way is not fraud. However, I would say, treat it like a minde field.
As a nurse educator, I am seeing more and more copy and paste nursing documentation which saddens me. I agree with Ms. Brent that “cloned documentation is often done when a nurse is trying to save time/or when a patient has not been assessed leading to errors continuously being forwarded in the patient’s record. This type of documentation can lead to [misdiagnosis] or improper care” (Brent, N. J.,2015). Copying and pasting shows a lack of proper care and skills that hopefully the nurse learned in school. Assessment skills and documentation are so important. I can understand copying and pasting vital signs as noted by the ICU nurse. However, it sends a message that the nurse is not performing his/her assessments. “I don’t have the time” is a chronic excuse that is unacceptable and is an insult to the nursing profession. Remember, we are the number one most trusted profession. Improper documentation and not performing assessments can lead to improper care which can lead to lawsuits and losing your nursing license.
Nursing isn’t a profession. Either a person I a professional or they are not. The diploma one gets, ADN, BSN, MSN, or DNP does not indicate a persons level of professionalism. Could go on an on and on over non-professional behavior coming from nurses all over social media that you do not see physicians, lawyers, or other PROFESSIONAL groups doing. And at what point can a person have a Bachelor’s in another field altogether and go to school for ONE year, one stinking year….and they’re nurses. Can you point to me where I can go to school one year and become a doctor, lawyer, PT/OT? No, because it’s not professional. The majority of people in nursing today are doing it bc they want to work 3 days a week, make good money, and have the “professional” tag. It’s dumb that nurses perpetuate this garbage.
Wow!
As a Professional nurse with many, many years experience under my belt, working very long hours for relatively poor pay and the constant necessity for continuous training in order to maintain my Professional registration with my Professional regulatory body!
I have never read such a poorly informed and provocative statement with so many grammatical errors.
Clearly a Pot/Kettle statement from a true perpetuator of garbage who knows very little of what they are talking about.
Well done for demonstrating your ignorance and taking the comments way off the subject matter in discussion!!!