For organizations that allow clinicians to carry forward clinical documentation in electronic records, auditing its proper use is key to ensuring document integrity. Copying clinical documentation poses both clinical and compliance risk. The feature “Auditing Copy and Paste” offers guidance in creating a solid audit plan.

The story is adapted from the broader AHIMA resource “Copy Functionality Tool Kit.” It offers sample policies, testing activities, case scenarios, and questions organizations can ask when considering the use of copy and paste.

You’ll find a lot of other good practice resources on that page.