Copy and paste by any other name : Cloning, carry-forward -- is not a rose!
Abstract
The copy and paste function in the electronic medical record (EMR) can turn into a thorn-in-the-side when ineffectively used by health care providers for documentation. Dimick identifies three wordsthat start with "C" to mean the same thing - copy and paste -- cloning -- carrying forward. Cloning can be defined in the following way; each note in a medical record is worded just like or similar to the previous entries for the same patient, or from one patient to another patient. This commonpractice can raise concerns about record credibility, plagiarism, and the risk of legal and monetary ramifications (i.e. malpractice, overbilling, and fraud). In addition, cloning can negatively impact on clinical decision making and make it difficult to find and prioritize current essential information abou the patient. Based on both personal record and article reviews most providers do not intentionally use copy and paste to provide ineffective patient care or distort or falsify documentation; often though, the end result from use of this technique can be compromised patient care and the inability to meet an insurer's requirement for documentation of medical necessity.
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