Use of copy and paste in Epic

Use of copy and paste in Epic

Epic’s copy functionality (i.e., copy/paste, cloning, copy forward, make me the author) can be used to create documentation that accurately reflects services provided on a given date, supports medical necessity and enhances care quality and safety. Electronic documentation tools can be more efficient and can standardize documentation, but using of copy functionality can result in redundant and erroneous documentation.

Providers are reminded not to copy the chief complaint or history of present illness (HPI) from a previous episode of care. This information must be newly documented for each visit. Notes from another provider should never be cloned as your own. When information populates patient history via smart text, be sure to verify the information with the patient so you do not perpetuate inaccuracies in the medical record. Copying sets of laboratory results or entire radiology results already recorded elsewhere in the medical record is discouraged. Pertinent findings should be summarized in lieu of populating the entire study or set of results.

Providers are responsible for the total content of their documentation. Previous notes with detailed patient history should be summarized or cross referenced and not copied into the current document. If the provider references another section of the medical record, detail should be provided to locate the note.

More information on the YNHHS “Use of copy functionality in electronic medical record” policy can be found on the intranet on MCN.