General Question for the Week of May 8, 2017

Question:

Our hospital coding and CDI professionals have noticed an increase in length and redundancy in clinical documents since we have implemented the electronic health record (EHR). For ex., some physician progress notes have exploded from three lines in a paper record to three or more pages in an electronic record with information being copied and pasted. Do you have any suggestions on ways to deal with this problem?

Answer:

In an effort to promote best practices regarding the copy-and-paste functionality (also referred as “cloning” or “carry forward”) available in most EHRs, the American Health Management Association (AHIMA) released a position statement on March 15, 2014, entitled “Appropriate Use of the Copy and Past Functionality in Electronic  Health Records,” which is available at http://bok.ahima.org/PdfView?oid=300306.

AHIMA gives several recommendations in regard to meeting the challenges and risks associated with this function. For example: Address proper use by developing policies and procedures (P&Ps), provide comprehensive training and education on the function to everyone involved in the EHR, and monitor compliance and enforce P&Ps and institute correction action if necessary.