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The Perils of Cut-and-Paste Documentation
HealthLeaders Media

It may sometimes seem easier for a physician to grab a block of prewritten text and paste it into a patient record. But while this quick cut-and-paste may shave a few minutes off initially, it can create some major headaches down the line, says Glenn Krauss, RHIA, BBA, CCS, CCS-P, CPUR, CCDS, C-CDI, an independent revenue cycle consultant in Burlington, Vermont.

Not only is this practice of copying and pasting without updating a note  a questionable billing practice, it also creates the potential for adverse patient outcomes as nicely summarized in a Joint Commission Quick Safety Issue February 2015 titled “Preventing copy-and-paste errors in EHRs,” he says.