Auditing Copy and Paste

CHICAGO, January 12, 2009—Copying clinical documentation saves time for clinicians but this “cloning” or “copy and paste” process may pose a risk to document integrity, according to an article in the January issue of the Journal of AHIMA.

Organizations that allow “carrying forward” clinical documents must ensure that copied documentation stays compliant with organizational, state and federal requirements that necessitate facilities utilizing the copy functionality in their electronic health systems to use system tracking or audit trails as a key element to ensure document integrity.

Auditing Copy and Paste discusses the process of copying existing test in the record and pasting it in a new destination, and ways to determine system audit capability. If organizational policy prohibits the use of copy and paste but the record system supports the action, then the facility must decide how this behavior will be monitored and measured. This article also details how organizations can develop an audit plan by first determining how providers plan to use the copy functionality.

Included in the article are two sidebars that present a sample copy of functionality testing and a sample copy audit policy. Also available is the “Copy Functionality Toolkit” that offers information on risk of fraud and abuse, education and training, case scenarios of proper and improper use, and sample sanction policy, education policy, auditing policy, and testing activities.

Read the complete article in the January issue of the Journal of AHIMA or online at journal.ahima.org.

About AHIMA

The American Health Information Management Association is America’s leading professional society whose mission is to “improve healthcare by advancing best practices and standards for health information management and [serve as] the trusted source for education, research and professional credentialing.” AHIMA represents more than 53,000 specially educated HIM professionals who serve healthcare and the public by managing, analyzing and utilizing data vital for health system management. www.ahima.org