Dream Factory by TruBridge Ideas Portal
Our compliance officer asked for a report to be able to track the copy/paste function. She states she saw this available on another EHR. This would be helpful to track acceptable levels of "cloning" with documentation. Thanks.
I believe we would want to see several things:
copied text by user by patient (at the profile and visit level) by author
was the text modified following copy - this could include being deleted as a modification
This would include when an entire note is copied forward.
I have actually read that when text is copied in from another author, it should be indicated in the documentation that the text did not originate from the author but from another source. Like in a research paper when you give credit. My first thought is with rad transcription that the provider copies in a note - it should indicate the original date/time and author of the interp. Now we have to ask our providers to state this information so it is manual. However we do use copy forward frequently.
Hey Cole, thanks for the idea. Are they curious on if copy/pasting has been done in general, on a particular Note, and how many times? Or are they wanting to have a detailed record of the specific text copied in, regardless of if maybe that text was later changed or deleted?