Nurses are responsible for documenting the care provided to hospitalized patients. Increasingly, this is being done electronically rather than by hand. Along with the advantages of the EMR, however, come new ethical questions.
One of these concerns is the ability to electronically “copy and paste” blocks of data from one area of the patient chart to another. Nurses can use this function to save time, but when is it ethical? Is it okay to copy a patient’s progress notes from yesterday and paste it into today’s report? If two patients are making similar progress, can you ethically copy and paste from one patient’s chart to another patient? And what about copying another nurse’s note and pasting it into the chart as if you wrote it yourself?
There is actually no research yet on how often nurses use the copy and paste function when documenting care. Yet we know it probably happens, given the statistics on how frequent the behavior is among physicians – a recent AHIMA report cited studies that demonstrated between 20 and 78 percent of physician’s notes contain copied text.
This issue of “cloned data,” as it is sometimes called, has attracted government scrutiny – largely over concerns that inaccurate data in the patient chart may cause hospitals to bill Medicare for services that were never rendered. A report issued by the Office of the Inspector General (OIG) found that only 25 percent of the hospitals surveyed had policies regarding the use of copy-and-paste functions in the EMR. Only 44 percent had any sort of audit trail that notes the method used to enter the data (e.g., keyboarding, voice recognition software, copy and paste).
The clinical consequences of cloned data
Nurses and doctors who use copy-and-paste functions carelessly may affect the quality of care in several ways. If the provider doesn’t go back and verify every single data point, there’s a huge risk of perpetuating errors in the chart. Even if an error has been corrected in the original record, it may have already been copied and brought forward to current notes, where it may lead to improper care or the wrong diagnosis.
Another problem has been dubbed “note bloat.” This occurs when too much information is pasted into the chart, above and beyond what is actually current or relevant – for example, notes might be carried forward from a patient encounter that is unrelated to the current condition. When the most current or relevant patient data is obscured or hard to find, patients may not receive the most appropriate level of care. [programpush poi=”MSNINF”]
Perhaps the most serious problems can result from data that is copied from one patient’s chart to another. It’s easy to see how a busy nurse might be tempted to do this – let’s say he or she is working on a maternity floor, caring for a number of postpartum patients that are recovering from a routine labor and delivery, without complications. The similarities between the cases might make copy-and-paste seem like a harmless way to save time on charting. Yet, serious data inaccuracies can result.
Cloning patient data can also subject a hospital to allegations of overbilling and fraud. If a provider inadvertently brings forward a diagnosis that no longer applies (like infection) or clones notes from a procedure that happened at a previous visit, the medical billing team cannot tell the difference and may bill for a new treatment or procedure.
Moving forward with ethics in mind
There may be appropriate ways to use copy-and-paste functions – for example, to record patient allergies, ongoing medications, and demographic data like address and phone number. It’s always a good idea to verify the data whenever possible, and to note that the data has been copied from another source, with attribution.
What else can be done? Hospitals can develop EMR content standards and specific documentation polices – and make sure all clinical staff members are aware of them. It’s also been suggested that technology vendors should include the ability to restrict copy-and-paste functions, or for copied text to be automatically identified as such. Certain types of data entry environments – template-based software, for example – may also reduce the temptation to cut and paste.
Remember, as a nurse, you are responsible for validating the data you enter into the EMR. Cloning data comes with significant legal and ethical risks. And if you have a keen interest in health care informatics, you might want to consider a career specialization in this area. Health care is in need of nurses who can analyze technologies from both the bedside and IT perspectives, to help create patient-centric tools. An online MSN degree in nursing informatics is the perfect way to improve your knowledge, skills, and value to your organization. American Sentinel University is an innovative, accredited provider of online nursing degrees.