Cut And Paste Medical Records

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Quick Safety 10: Preventing copy-and-paste …

https://www.jointcommission.org/resources/news-and-multimedia/newsletters/newsletters/quick-safety/quick-safety--issue-10-preventing-copy-and-paste-errors-in-ehrs/preventing-copyandpaste-errors-in-ehrs/

American Health Information Management Association: “ Appropriate Use of the Copy and Paste Functionality in Electronic Health Records.” AHIMA Position Statement (accessed February 10, 2015) Additional resources: Partnership for Health IT Patient Safety. Health IT Safe Practices: Toolkit for the Safe Use of Copy and Paste. February 2016.

EHR Copy and Paste and Patient Safety | PSNet

https://psnet.ahrq.gov/perspective/ehr-copy-and-paste-and-patient-safety

Perspective. Although the ability to copy and paste text is a central benefit of computing in general, and electronic health records (EHRs) in particular, the widespread …

Note bloat: problems with cut and paste - Today's …

https://www.todayshospitalist.com/note-bloat-electronic-health-records/

The use of electronic medical records can bring note bloat and cloned notes, both big problems for physicians, no matter their …

Copying and Pasting in EHRs | Duke Health Referring …

https://physicians.dukehealth.org/articles/copying-and-pasting-ehrs

Overuse or incorrect use of the copy and paste feature in EHRs can be dangerous and can have legal ramifications, including insurance fraud or loss of money from billing errors due to convoluted …

Department of Health and Human Services

https://oig.hhs.gov/oei/reports/oei-01-11-00571.pdf

When doctors, nurses, or other clinicians copy-paste information but fail ... patient’s medical record and inappropriate charges may be billed to patients and third-party health care …

Q&A: Taking a stand on medical record copy and paste …

https://acdis.org/articles/qa-taking-stand-medical-record-copy-and-paste-functionality

Ask your coding supervisor or manager to better understand your organization’s policies around the electronic medical record, specifically the cut and …

Auditing Copy and Paste - AHIMA

https://library.ahima.org/doc?oid=87789

Copying forward clinical documentation is the process of copying existing text in the record and pasting it in a new destination. Clinicians may use it to save time when updating …

Is copy and paste an acceptable form of patient care …

https://www.nurse.com/blog/is-copy-and-paste-an-acceptable-form-of-patient-care-documentation/

Dear Carl, Using the copy and paste function with electronic medical records is a questionable ethical and legal manner in which to document patient care. ”Cloned” …

Medical record cloning: When documenting, avoid the …

https://www.reliasmedia.com/articles/62436-medical-record-cloning-when-documenting-avoid-the-temptation

This is the overarching criterion for determining medical necessity for Medicare. Word processing software, EMRs, voice recognition software, and templated …

Guidelines for Copying and Pasting Medical Records

https://www.utmb.edu/policies_and_procedures/IHOP/Supporting_Documents/IHOP%20-%2009.02.15%20-%20Medical%20Record%20Documentation%20(Guidelines%20for%20Copying%20%20Pasting%20%20Medical%20Records).pdf

Guidelines for Copying and Pasting Medical Records 1. Copying information from prior notes may be appropriate when: a. It is based on external sources, such as …

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