As EHR implementation and adoption continue to accelerate across the country, the documentation practices are under increased scrutiny. The use of the copy and paste functionality in an organization’s EHR must be defined, trained and audited for appropriate use. This toolkit is designed to assist HIM professionals in developing their own policies and procedures surrounding this functionality.
Topic Areas include:
- Identify the risks of copy and paste
- Discuss when the copy functionality may be appropriately used in the health record
- Address fraud and abuse billing concerns when duplicate documentation is identified
- Education and training for providers and the risk of duplication documentation and ensuring the integrity of the heath record
- Audit for compliance through audit plan and work lists
- Sample policies and procedures