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DOCUMENT TITLE:
Copy and Paste Notes in the Electronic
Medical Record
SYSTEM POLICY AND PROCEDURE
MANUAL
POLICY #: 800.63 CATEGORY: Compliance & Ethics
System Approval Date:
4/23/2024
Site Implementation Date:
4/23/2024
Origination Date: 03/16/2017
Previously Reviewed/Approved:
02/23/2023
Prepared by:
Office of Corporate Compliance
Notations:
GENERAL STATEMENT of PURPOSE
The purpose of this document is to establish that Electronic Medical Record (EMR) copy and paste
functions shall be used by clinicians appropriately to enhance patient safety, minimize non-
compliance and ensure the data is accurate and current at the time the information is recorded.
POLICY STATEMENT
It is the policy of Northwell Health that all copied and pasted information within the electronic
medical record must be verified prior to final submission.
SCOPE
This policy applies to all Northwell Health employees, as well as medical staff, volunteers,
students, trainees, physician office staff, contractors, trustees and other persons performing work
for or at Northwell Health; faculty and students of the Donald and Barbara Zucker School of
Medicine at Hofstra/Northwell or the Hofstra Northwell School of Nursing and Physician
Assistant Studies conducting research on behalf of the Zucker School of Medicine on or at any
Northwell Health facility; and any other Affected Individual.
DEFINITIONS
Addendum: An entry to a medical record to provide additional information after the original
document has been authenticated or signed by a provider. The entry should be documented as an
“Addendum,” and include the current date, time and signed by the provider.
Affected Individuals: As per Title 18 NYCRR, Part 521 “Affected Individuals” is defined as all
persons who are affected by Northwell Health’s risk areas including Northwell Health’s
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employees, the chief executive and other senior administrators, managers, contractors, agents,
subcontractors, independent contractors, and governing body and corporate officers.
Copy and Paste: While documentation may exist where it is worded exactly like previous entries,
“Copy and Paste” typically refers to medical record documentation that has been copied and
pasted, copied forward or cloned from another source location. Consequently, copied and pasted
documentation may not accurately reflect current information which is specific to the patient
encounter being documented. One or more of the following functions may be used within an EMR
to clone:
1. Copy and paste;
2. Copy forward;
3. Save note as a default template;
4. Use of boilerplate;
5. Any other function that allows an individual to copy information from one patient visit note to
the current visit for either the same or a different patient.
PROCEDURE
According to the Centers for Medicare and Medicaid Services (CMS), whether documentation is
a result of an EMR, pre-printed templates, or handwritten documentation, inappropriately cloned
documentation will be considered a misrepresentation of the medical necessity requirements for
coverage of services, due to lack of specific individual information for each unique patient.
Clinicians must recognize that every patient is unique and must be sure that the services provided
are documented distinctly from all other visits or patients.
Utilizing defaulted documentation also may cause a provider to overlook significant new findings
that may result in safety/quality of care issues, as well as denial of services for lack of medical
necessity.
In order to protect and enhance patient safety, clinical documentation, regardless of how it is
created, must be accurate, reliable, and timely. The time-saving efficiencies of reusing information
in the electronic environment through copy and paste to document complex medical conditions
can ensure completeness of encounter documentation and generally produces fewer transcription
errors.
Acceptable Practices
While there can be value to the selective and careful copying of information within a patient’s
medical record, copying and pasting shall be done selectively and thoughtfully and with the goal
of producing a clear, useful and accurate patient note. When used appropriately, it reduces errors
of omission in transcription and minimizes inclusion of incorrect information. Northwell Health
standards for electronic documentation include:
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1. Entries shall be accurate, relevant, timely and complete.
2. Clinician entries must accurately reflect the clinical work performed on each separate date of
service. The clinician signing the note acknowledges their responsibility for the accuracy of
the content of that note including any copied and pasted information. Notes will be reviewed
and signed according to Northwell Health policy #800.20 - Physician Signature Requirements.
3. Applicable lab, pathology and radiology results shall be summarized in clinician
documentation, or have interpretation of portions copied.
4. Any entries made in error shall be modified in accordance with Northwell Health Policy
#200.14 – Modifications in the Medical Record.
Unacceptable Practices
Although clinicians may utilize “Copy and Paste” as clinically appropriate, the following are
prohibited practices:
1. Copying and Pasting documentation without verifying, editing and/or updating as appropriate.
2. Copying and Pasting inaccurate or outdated information that may adversely impact patient care
and reimbursement.
3. Propagation of false information.
4. Copying and Pasting inconsistent progress notes.
5. Not identifying when the documentation was created.
6. Copy and Pasting in the EMR without noting the original author (unless the author is yourself),
date and time of entry.
Non-Compliance and Auditing
Any misuse of Copy and Paste or Copy Forward shall be reported to the Office of Corporate
Compliance.
The Office of Corporate Compliance will periodically monitor, measure and assess the EMR for
documentation integrity and ensure that copied documentation follows all appropriate
organizational, state, and federal requirements.
REPORTING AND ENFORCEMENT
All violations of this policy shall be reported to the appropriate manager/supervisor/director or to
the Office of Corporate Compliance (516-465-8097) for appropriate resolution of the matter. The
HelpLine is available 24 hours a day, seven days a week at (800) 894-3226 or online at
www.northwell.ethicspoint.com, is accessible to all Affected Individuals and allows for questions
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regarding compliance issues to be asked and for compliance issues to be reported. Reports of
potential fraud, waste and abuse and compliance issues also may be made directly to the Chief
Corporate Compliance Officer or designee in person, in writing, via email, mobile device via a
QR code, or by telephone. All reports received by the Office of Corporate Compliance are
investigated and resolved to the fullest extent possible. The confidentiality of persons reporting
compliance issues shall be maintained unless the matter is subject to a disciplinary proceeding,
referred to, or under investigation by Medicaid Fraud Control Unit, U.S. Department of Health and
Human Services (HHS), Office for Civil Rights, HHS, Office of Inspector General Office
of
Medicaid Inspector General or law enforcement, or disclosure is required during a legal
proceeding, and such persons shall be protected under Northwell Health’s policy for non-
intimidation and non-retaliation. Violations of this policy will be subject to disciplinary action as
outlined in the Human Resources Policy and Procedure Manual and Northwell Health Policy
#800.73 – Compliance Program Disciplinary Standards for Non-Employees.
REFERENCES to REGULATIONS and/or OTHER RELATED POLICIES
• Northwell Health Policy #800.20 Physician Signature Requirements
• Northwell Health Policy #200.13 Patient Request for Medical Record Amendment
• Northwell Health Policy #200.14 Modifications in the Medical Record
• Joint Commission Standard RC.01.02.01
• Joint Commission Standard RC.01.03.01
• OMIG Compliance Program Guidance, Title 18 NYCRR § 521 – Fraud, Waste and Abuse
Prevention (March 28, 2023)
• Northwell Health Policy #800.73 – Compliance Program Disciplinary Standards for Non-
Employees
• Northwell Health Human Resources Policy and Procedure Manual, Part 5-3 – Workforce
Conduct – Progressive Discipline
CLINICAL REFERENCES/PROFESSIONAL SOCIETY GUIDELINES
• ECRI: Safe Practice Recommendations for Copy and Paste
ATTACHMENTS
N/A
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FORMS
N/A
CURRENT REVIEW/APPROVAL:
Service Line/Department Review 04/10/2024
Northwell Health Policy Committee
04/23/2024
System PICG/Clinical Operations Committee
04/23/2024
Standardized Versioning History:
Approvals: * =Northwell Health Policy Committee; **=PICG/Clinical Operations Committee;
=Provisional; =Expedited
*02/22/17 **03/16/17
*01/31/19 **02/15/19
*01/27/21 **02/18/21
*01/24/23 **02/23/23
