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HOME > FPP POLICIES > EMR-Data Replication Policy

 EMR - Data Replication Policy

 

Printable Version of Policy

Approved:  October 13, 2009

 

 Data Replication: Utilization of Copy Functionality in the Electronic Medical Record (EMR)

PURPOSE: 

The purpose of this policy is to establish parameters as to the degree which providers/users may use the “copy” functionality when documenting in the EMR.  For the purpose of this policy copy shall include copy/paste, copy forward, cloning and any other intent to move documentation from one part of the record to another.

POLICY: 

A medical record is created for every patient who receives treatment, care, or services at WUSM and is maintained for the primary purpose of providing patient care.  The record shall contain sufficient information to identify the patient, support the diagnosis (es), justify treatment, document the course and results and facilitate the continuity of patient care.  Documentation must be accurate and concise.  Providers documenting in the EMR must avoid indiscriminately copying and pasting progress notes and duplicate/redundant information provided in other parts of the EMR.

PROCEDURE:

  1. Providers are responsible for the total content of their documentation, whether the content is original, copied, pasted, imported or reused. 

  1. If any information is copied or reused from a prior note, the provider is responsible for its accuracy and medical necessity. Progress notes are to provide an accurate depiction of treatment surrounding a specific date of service.
    • Copied information must be reconfirmed and revised as necessary to accurately reflect the specific date of service.
    • It is unnecessary to duplicate information that does not specifically impact a specific date of service.

  1. Providers are limited to copying from their own office notes (exception: see #4).   Information that is copied must meet the following requirements:
    • Copying is limited to progress notes of a specific individual patient (i.e. copying from one patients notes to another patients record is prohibited).
    • Copying of subjective data (i.e. history of present illness and plan of care) is strongly discouraged.
    • Copying teaching physician attestations from previous notes is prohibited.
    • Information that is copied should not exceed six (6) months from the date of the original note. 
    • Information copied forward from the providers original notes should be closely examined for accuracy, completeness and relevance.
    • Documentation must include the following:

                       i.   Copied information must be attributed to the original source,

                      ii.   Reference the date of the original note, and

                     iii.   Reference the location of the original note if not within the same EMR

                     iv.   Example: “Copied from my previous note dated…”

  1. In most cases, providers are responsible for citing and summarizing applicable lab data, pathology, and radiology reports rather than copy such reports in their entirety in the notes.
    • Occasionally, lab data, pathology results and radiology reports may be helpful in clarifying treatment and it is appropriate, on a selective basis, to include specific results.
    • Copying of demographic information and other information nonessential to clinical care (e.g. CLIA or lab certification specifications) is discouraged.
    • Documentation must include the following:

                       i.   Copied information must be attributed to the original source/provider, and

                      ii.   Reference the date of the original note.

                     iii.   Example:  “Below is a copy of Dr. Radiologists interpretation dated….”

  1. Providers are responsible for correcting any errors identified within their own document, via an amendment if the note is already signed.

o   Any errors in provider’s original source notes must be corrected, also via an amendment. 

o   All notes copied from the original source that contains errors must be corrected.  If the information is copied from, for example, a lab, pathology or radiology report, the author should be contacted to discuss and correct the original document and this should be noted in the provider’s current note.

  1. Providers are required to document in compliance with all federal, state and local laws as well as with University policy.
 
     
    Washington University Physicians