A hospital employee navigated a violation on electronic documentation. What documentation practice creates a risk of violations?

Copying information from previous notes in electronic documentation can create a significant risk of violations, especially concerning accuracy and the legal integrity of medical records. When healthcare providers copy and paste information from earlier notes, there may be a lack of current context or updates regarding a patient's condition. This practice can lead to outdated or incorrect information being propagated throughout a patient's medical record, potentially compromising patient safety and care quality. Additionally, it raises concerns about the authenticity of the documentation, as it can make it difficult to ascertain which medical information was actually observed or assessed during a patient encounter versus what was merely replicated from a previous note. This can also contribute to billing compliance issues, as it may lead to inaccurate claims based on non-updated patient information.

In contrast, limiting access to patient records is a precautionary measure to enhance confidentiality and protect patient privacy. Using electronic prompts for documentation aids in guiding healthcare providers through necessary information to ensure standardized and complete entries, thereby promoting accuracy. Regularly auditing all entries serves as a quality control measure to identify errors and ensure compliance with documentation standards, thus promoting accuracy and accountability in patient records.