With many hospitals and medical providers still in the early adoption stages of EHR, objections or problems with the various systems are still just coming to light. However, one particularly growing concern is providers using the copy-paste or copy-forward function in patient records. This is a shortcut that many physicians have found to be handy after the implementation of the new system, however using it actually can violate patient confidentiality and HIPPA rules, and lead to fraud or malpractice lawsuits and federal or payer audits. More importantly, the misuse of these functions can negatively affect patient care.
In using copy-forward or copy-paste incorrectly, physicians or nurses can affect patient care in several ways. The first problem is when providers copy more information than what is actually relevant – say pages of labs from an unrelated issue – and paste it with their notes. This creates “note bloat” in the EMR system, which makes it more difficult for other providers to interpret the last physician’s notes and decipher what the patient’s current issue is and what issues listed have already been resolved.
A more serious concern is when information is copied from one patient’s record to another. This can lead to incorrect information being stored on a patient’s EMR record, and can also lead to HIPAA violations if any of the original patient’s information is stored on another patient’s chart.