nursing documentationNurses are responsible for documenting the care provided to hospitalized patients. Increasingly, this is being done electronically rather than by hand. Along with the advantages of the EMR, however, come new ethical questions.

One of these concerns is the ability to electronically “copy and paste” blocks of data from one area of the patient chart to another. Nurses can use this function to save time, but when is it ethical? Is it okay to copy a patient’s progress notes from yesterday and paste it into today’s report? If two patients are making similar progress, can you ethically copy and paste from one patient’s chart to another patient?

And what about copying another nurse’s note and pasting it into the chart as if you wrote it yourself?

How widespread is the practice?

There is actually no research yet on how often nurses use the copy and paste function when documenting care. Yet we know it probably happens, given the statistics on how frequent the behavior is among physicians. A recent AHIMA report cited studies that demonstrated between 20 and 78 percent of physician’s notes contain copied text.

This issue of “cloned data,” as it is sometimes called, has attracted government scrutiny. It is largely over concerns that inaccurate data in the patient chart may cause hospitals to bill Medicare for services that were never rendered.

A report issued by the Office of the Inspector General (OIG) found that only 25 percent of the hospitals surveyed had policies regarding the use of copy-and-paste functions in the EMR. Only 44 percent had any sort of audit trail that notes the method used to enter the data (e.g., keyboarding, voice recognition software, copy and paste).

The clinical consequences of cloned data

Nurses and doctors who use copy-and-paste functions carelessly may affect the quality of care in several ways. If the provider doesn’t go back and verify every single data point, there’s a huge risk of perpetuating errors in the chart. Even if an error has been corrected in the original record, it may have already been copied and brought forward to current notes, where it may lead to improper care or the wrong diagnosis.

Another problem has been dubbed “note bloat.” This occurs when too much information is pasted into the chart, above and beyond what is actually current or relevant. For example, notes might be carried forward from a patient encounter that is unrelated to the current condition. When the most current or relevant patient data is obscured or hard to find, patients may not receive the most appropriate level of care.

What are your thoughts on copying and pasting blocks of data from one area of the patient chart to another?  Is it ethical?

 

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