Why It Isn’t a Good Idea to Copy and Paste Text in Medical Records

Technological advances have changed everything, including the healthcare industry. You don’t have to carry around a thick folder with a patient’s records anymore.

And you may be able to paste text to save time during a visit. But copying and pasting patient records can cause problems.

Keep reading to learn why you may not want to copy and paste text when working with patient health records.

Outdated Information

One of the reasons why you shouldn’t use copy-paste is that you could accidentally copy outdated information. You could copy the same data from visit to visit, so the patient’s chart may not have anything new.

While copying can save time, people rarely stay the same for months. If a patient comes in with a new complaint, you need to take the time to log it.

Logging it manually will ensure that it is accurate and complete. You may not need to use a ton of details when typing, but you do need to make the record unique to the patient.

That way, you can review this visit the next time the patient comes in. You and your patient will have an accurate log of the visit and what you did to help.

Care Can Change

If you treat patients in a hospital setting, you shouldn’t paste text. Even in a short hospital stay, care and diagnoses can change.

You should always take time to type out the main complaint and treatment when someone first comes in. But after some tests, you may find out that the problem is something else.

If you just copy and paste text from the initial consultation, you won’t have the full picture. Your patient records should show the change, and that means typing things out as they change.

Even if you don’t change the care plan or diagnosis, you should still avoid copying and pasting. A patient should be able to read their electronic health record (EHR), and varying the text you use may help clarify things.

From Another Patient

Perhaps you have two patients with very similar conditions. Your first patient comes in, and you discover they have a skin condition. You diagnose the problem and prescribe them some medication.

A day or so later, your second patient comes in with similar symptoms. So you diagnose them with the same problem and give them the same treatment.

In that case, it can be very tempting to copy and paste text across health records. But that can be risky, especially if you copy and paste too much.

Patient records should be confidential. Even when two people have similar conditions, you should type those records separately. That way, you won’t accidentally copy more information into the second patient’s EHR.

Accidental Falsification

Whenever you copy and paste text, you should make sure you know what you’re copying. Consider if you wrote the initial version of the notes or if someone else did.

In either case, you could accidentally falsify medical records. If you copy someone else’s notes, you won’t have control over if those were accurate.

And when copying your own notes, you may make a mistake. Errors can happen in a medical facility, but you need to do what you can to minimize their occurrence.

If you accidentally copy and paste text that’s incorrect, you could lose your medical license. A court may not be lenient if they find out it’s an accident, so you should do everything you can to avoid it.

No Original Source

Another problem of copying and pasting happens when you can’t find the original source. Whether you copy and paste text from the same patient’s files or that of someone else, you should know where it first appeared.

If you keep copying and pasting the same information, you probably won’t remember the original source. When that happens, it can be hard to trace your steps when things change.

The more you copy and paste the same information, the bigger a problem this can get. Even if records don’t change much, you should still write them from scratch.

That way, you will know when you first wrote that information. You’ll be able to track changes more easily, and you won’t accidentally copy something you shouldn’t.

When Copy and Paste Can Help

While copying and pasting can cause problems in the healthcare industry, it can help occasionally. If you do need to save time on patient records, you can paste text in a few situations.

Here’s when you may want to know how to copy and paste on a Mac or Windows computer for medical records.

Patient Contact Information

An excellent use of the copy and paste function is when working with patient contact information. Odds are your patient’s name and address won’t change frequently.

As long as you verify that everything is accurate, you can copy and paste someone’s name and address. You may also be able to copy and paste text for a patient’s phone number and medications.

Consider if the thing you want to copy and paste could have changed. If it did, you may want to start the log from scratch to avoid errors.

But if a patient has lived at the same address for years, there’s no need to write that out again. You can copy and paste the address fields to save a bit of time.

Patient Allergies

While some people can experience a change in their allergies, that won’t happen all of the time. That makes logging someone’s allergies a good use for the copy and paste text function.

You can verify that your patient has all of the same allergies. That way, you can copy and paste that information for the current visit.

The same is true if your patient has one or more chronic conditions. While some conditions go away, the patient may still have that diagnosis.

The Problem With Copy and Paste Text

Copying and pasting can decrease the time you spend on a patient’s electronic health record. But if you aren’t careful, it could lead to inaccurate records.

You could provide the wrong treatment to a patient, or you could lose your license. So make sure you know when it’s appropriate to copy and paste text or not.

Did you enjoy this article? Check out the health section on our blog for similar content.

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