As you follow the patient throughout their visit, documentation of the critical elements in the EMR is super important. Often times, we use copy & paste to make our documentation easier or faster. However, sometimes we really need to read what was already written and only add the new information because things have changed.

I have witnessed some not-so-good copy & pasting a few times. I have read where a patient has had treatment and is now ambulating with a device. However, the copied information states otherwise. Who is correct? What should I document on the data collection forms?

I have seen where one person documents that a patient is left handed. However, another person recorded they were right handed. What should I record?

This does not happen often, but when it does, it can be confusing and causes more time for me to figure out which information I should use.

So bottom line: be careful when copying & pasting existing exam notes, or progress notes, and ensure the information you are copying & pasting is accurate across the board.

Our databases are only as good as our documentation within the EMR.