Electronic health record (EHR) documentation is exponentially longer and less efficient today than in the past decade.1-3 Research suggests one factor contributing to over-documentation is the excessive use of the copy-paste function (CPF), resulting in the redundancy of data over 50 percent of the time.4-7
The overuse of the CPF and redundancy of information are directly linked to errors in safety practices and health outcomes.8-12 Solutions are needed to support the use of informatics and technology features in useable and safe measures. Best practices for using the CPF in documentation centers on principles that maintain the integrity of the electronic documentation. Evidence suggests process improvements are necessary, such as policies, procedures, education, and programming functionality are critical to preserving the integrity of the CPF and safe health outcomes.13-15
Electronic documentation is a valuable tool in healthcare. Key features of technology systems provide users with time-saving options such as duplicating and transferring information. A resulting consequence is documentation overload or “note bloat,” loss of relevant data, and safety errors.16-18 This article aims to describe measures to minimize the redundancy of electronic documentation and promote safe patient outcomes by enhancing the integrity of the CPF.
Documentation in the EHR serves as an interdisciplinary communication tool and as a legally binding record.19,20 In efforts to use time efficiently, users of the EHR adopted time-saving practices such as copying and pasting when entering data that was without changes. Examples in the clinical setting include diagnosis and past medical history. In an outpatient setting, recent visits contain data that is consistent, such as the problem list and patient history. Research suggests the CPF is a valuable feature in EHR documentation when used in tandem with up-to-date, relevant information that is applicable for ensuring safe, appropriate care.21-23
Safety in healthcare is at the forefront when patient care is involved. However, many healthcare workers do not adhere to policies and procedures set in place. Inappropriate utilization of the EHR by practitioners is a danger to patient care and the providers associated with the treatment of each individual patient. Potential litigation is a possible negative outcome encountered by organizations when clinicians under-document or commit documentation errors in the EHR. Some of the occasions these errors in documentation occur involve staff not fully understanding processes and policies being taught during new-hire training. Safety issues that are currently overlooked include allergies, comorbidities, and past medical history. These are important components in an electronic healthcare record to facilitate safe patient care. Not only is it imperative to ensure patient safety, quality of care is also at the forefront. Many clinicians use copy and paste in the electronic health record, which has been linked to 2.6 percent of errors in patient care.24 These errors resulted from copy and pasting within another patient’s chart, internal inconsistencies, and fault propagation.25 The first thing that must be done to ensure safety and quality of care for all patients is to increase compliance within the current processes through appropriate training and education.
Advantages in time savings, which equals cost savings, and potentially negative outcomes associated with the use of CPF will require individual facilities to address specific procedures to be used with their respective clinical practitioners. This issue is one that all types of healthcare facilities with an EHR will need to address. Organizations will be called upon to determine if the same policies and procedures will apply to all individuals with documentation privileges in the EHR within the healthcare facility, or will carve outs occur and only physicians and/or nurses be allowed to utilize these time saving documentation capabilities. Further study is necessary to determine the future of the CPF in relation to how it is used, who can use this function, and appropriate training and education needed within healthcare facilities.
1. Gantzer, H., Block, B., Hobgood, L., & Tufte, J. (2020). Restoring the story and creating a valuable clinical note. Annals of Internal Medicine, 173(5), 380–382. https://doi.org/10.7326/M20-0934
2. Harrington, L. (2021). Is Electronic Health Record Safety a Paradox? AACN Advanced Critical Care, 32(4), 375–380. https://doi.org/10.4037/aacnacc2021406
3. Rule, A., Bedrick, S., Chiang, M., & Hribar, M. (2021). Length and redundancy of outpatient progress notes across a decade at an academic medical center. JAMA Network Open, 4(7), e2115334–e2115334. https://doi.org/10.1001/jamanetworkopen.2021.15334
4. Cheng, C., Wu, D.-C., Lu, J.-C., Yu, C.-P., Lin, H.-L., Wang, M.-C., & Cheng, C.-A. (2022). Restricted use of copy and paste in electronic health records potentially improves healthcare quality. Medicine (Baltimore), 101(4), e28644–e28644. https://doi.org/10.1097/MD.0000000000028644
5. Rowlands, S., Tariq, A., Coverdale, S., Walker, S., & Wood, M. (2020). A qualitative investigation into clinical documentation: why do clinicians document the way they do? Health Information Management, 1833358320929776–1833358320929776. https://doi.org/10.1177/1833358320929776
6. Rule, 2021.
7. Tsou, A., Lehmann, C., Michel, J., Solomon, R., Possanza, L., & Gandhi, T. (2017). Safe practices for copy and paste in the EHR. Applied Clinical Informatics, 26(1), 12–34. https://doi.org/10.4338/ACI-2016-09-R-0150
8. Berry, B., Campbell, A., Flanigan, J., Paulson, D., Ryznar, B.,& Woebkenberg. J.(2019). Ensuring the Integrity of the EHR (Part One). Journal of AHIMA, 90(1), 34–37.
9. Cheng, 2022.
10. Harrington, 2021.
11. The Joint Commission, Division of Health Care Improvement. (2021). Preventing copy-and-paste errors in EHRs.
12. Tsou, 2017.
13. Berry, 2019.
14. Cheng, 2022.
15. Tsou, 2017.
16. Davey, A. & Borycki, M. (2021). Copy and paste in the electronic medical record: A scoping review. Knowledge Management & e-Learning, 13(4), 522–535. https://doi.org/10.34105/j.kmel.2021.13.028
17. Rule, 2021.
18. Tsou, 2017.
19. Cheng, 2022.
20. Rowlands, 2020.
21. Cheng, 2022.
22. Rowlands, 2020.
23. Tsou, 2017.
Dewanna Blake is an associate professor of nursing.
Brittney Helton is an assistant professor of nursing.
Sherry Peveto is an assistant professor of nursing.
Joanna Ward is an assistant professor of health informatics.
Michelle Martin is an associate professor of health informatics.