How to Reduce the Risk of Copy and Paste

by  Erica E. Remer, MD CCDS
Apr 27th, 2022

Providers should never C&P material they have not read nor vetted for accuracy.

A young Jeopardy! champion died from bilateral pulmonary emboli following a colectomy in January 2021. Following his surgery, it was reported that the surgeon referred to “DVT/VTE Prophylaxis/Anticoagulation” and another note read, “already ordered.” “DVT Prophylaxis” was mentioned in the progress notes, but on analysis, it was determined that the order had never been entered and executed. Although DVT prophylaxis has long been my apocryphal example of dangerous copy and paste, one could certainly envision the phrase, “DVT prophylaxis,” being copied and pasted ad infinitum to the patient’s detriment and demise in this case.

It occurs to me that my email alerts me when I have used the word, attached, in the body of an email without affixing an attachment. I think they should program the electronic health record (EHR) to trigger an alert if any variation of “DVT prophylaxis” is documented in a note if there is no anticoagulation ordered. In fact, there are other instances when this function might be useful, like if antibiotics are alluded to but no order had been placed. The provider would be given the opportunity to rectify the lapse prior to an adverse outcome. But I digress. I am preparing to rail against copy and paste (C&P).

It is not my nature to complain about an issue without offering solutions. This article is going to be referencing Partnership for Health IT Patient Safety’s “Health IT Safe Practices: Toolkit for the Safe Use of Copy and Paste” from February 2016. I strongly recommend reading it and implementing their recommendations.

I like their definition of copy and paste: “data that is volitionally obtained and used elsewhere without having to retype any of the information.” When I teach my two-day course on medical documentation for folks who have gotten in trouble with their Medical Boards, I have them consider why we never used to have this issue in the days of paper records. It would be too time consuming to copy the note from yesterday over into today’s documentation. We would spend a few moments determining what points were critical to be documented today to avoid wasting time. This is, of course, how we are in the pickle we are in now. Convenience is compelling, and it takes only a click of a mouse to copy large swathes of text whereas typing discrete, essential details would take more precious time. Additionally, reviewing what was just deposited into today’s note and revising, editing, and deleting the information to make it accurately reflect today’s situation can be very labor-intensive.

The toolkit includes autofill and autocomplete in the actions which may adversely affect the data integrity of documentation. I will also include prepopulating and templating. All of these may result in inaccurate, inconsistent, outdated, irrelevant, redundant, or incorrect information. Other risks are note bloat (inordinately long notes) and the inability to distinguish new or important information from reused or recycled information.

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Read the entire article at ICD10monitor by clicking here.

This article originally published on April 25, 2022 by ICD10monitor.

About Erica E. Remer, MD CCDS

Erica Remer, MD, FACEP, CCDS, has a unique perspective as a practicing emergency physician for 25 years, with extensive coding, CDI, and ICD-10 expertise. As physician advisor for University Hospitals Health System in Cleveland, Ohio for four years, she trained 2,700 providers in ICD-10, closed hundreds of queries, fought numerous DRG clinical determination and medical necessity denials, and educated CDI specialists and healthcare providers with engaging, case-based presentations. She transitioned to independent consulting in July 2016. Dr. Remer is a member of the ICD10monitor editorial board and is the co-host on the popular Talk Ten Tuesdays weekly, live Internet radio broadcasts.