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?
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 This responsibility means you never use outdated data over and over again to save time.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.