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Cited by 7Electronic Health Records SystemsNursing Diagnosis and DocumentationMedical Coding and Health Information

Copy and paste in the electronic medical record: A scoping review

Open access
Amirav Davy, Elizabeth Marie Borycki, | |·2021·Knowledge Management & E-Learning: An International Journal
DOI 10.34105/j.kmel.2021.13.028
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Abstract

Copy and paste (CPF) can be defined as the act of duplicating medical documentation from one section of the electronic medical record (EMR) and placing it verbatim in another section. The objective of this scoping review is to: 1) describe the prevalence of copy and paste usage in EMR documentation, 2) detail the known measurable safety hazards associated with its use, and 3) identify potential solutions and/or strategies that can be used to mitigate the negative consequences of the CPF while preserving its essential role in documentation efficiency. The Joanna Briggs Institute guidelines were used to identify, screen, and assess the text of articles for final inclusion in CPF article review. The primary search strategy for copy-paste articles was developed in PubMed® and then translated to CINAHL®, ScienceDirect®, and IEEExplore® to extract additional articles. Identified copy-paste articles were imported into Covidence®. Two reviewers determined the final articles that were included in the review. The search retrieved 63 publications of which 17 were identified for final inclusion. The scoping review revealed CPF of medical text is a common occurrence that cuts across all clinician types (e.g., physicians and nurses). The scoping review revealed that automated methods for finding duplication in electronic documentation had emerged. A limited number of studies with quantifiable harms associated with CPF were found. Clinicians stated that CPF: 1) had a negative impact on critical thinking, 2) led to medical complications being more likely to be overlooked, and 3) led to safety issues being missed with copy-paste content. A few different approaches were tested by researchers as alternatives to CPF. They included dictation systems, practice guidelines, note templates, highlighting of copied information, note splitting, and text insertion. CPF is long overdue for innovative approaches to minimizing patient risk and maximizing provider efficiency.

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  • Patients' conditions may be updated inaccurately if clinicians heavily rely on the copy-paste function, raising the risk of errors in the following patient care.

    “Patients’ conditions may be updated inaccurately if clinicians heavily rely on the copy-paste function, raising the risk of errors in the following patient care [184].”

    From Toward Safer Diagnoses: A SEIPS-Based Narrative Review of Diagnostic Errors (2026) · cites this paper as [184]

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1 of the 28 references couldn’t be matched to a known paper.

Research works printed but not linked: 5

  1. Dean, S. M., Eickhoff, J. C., & Bakel, L. A. (2015). The effectiveness of a bundled intervention to improve resident progress notes in an electronic health record (EHR). Journal of Hospital Medicine, 10(2), 104-107.
  2. Hirschtick, R. E. (2006). Copy-and-paste. JAMA, 295(20), 2335-2336.
  3. O'Reilly, K. (2013). EHRs: "Sloppy and paste" endures despite patient safety risk. American Medical News. Retrieved from https://amednews.com/article/20130204/profession/130209993/2/
  4. Tsou, A. Y., Lehmann, C. U., Michel, J., Solomon, R., Possanza, L., & Gandhi, T. (2017). Safe practices for copy and paste in the HER: Systematic review, recommendations, and novel model for health IT collaboration. Applied Clinical Informatics, 8(1), 12- 34.
  5. Wilson, J. (2014). Copy and paste function in the EHR: Steps compliance officers can take to encourage proper use. Journal of Health Care Compliance, 16(6), 67-70.

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Authors
Davy, A., Borycki, E. M., & |, |.
Affiliations
University of Victoria (CA)
ORCID
Elizabeth Marie Borycki
Venue
Knowledge Management & E-Learning: An International Journal
Publisher
Laboratory for Knowledge Management and E-Learning - The University of Hong Kong
Published
2021-12-30
Pages
522-535
ISSN
2073-7904 (ISSN-L)
DOI
10.34105/j.kmel.2021.13.028
OpenAlex
W4225336157
Cited by
5
References
28
Citations by year
2025: 1 · 2024: 2 · 2023: 1 · 2021: 1
FWCI
0.87
Type
journal article
Language
en
Open access
Licence
cc-by
Locations
  • Knowledge Management & E-Learning An International Journal (publishedVersion, cc-by)
  • DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
Topics
  • Health Sciences › Health Professions › Health Information Management › Electronic Health Records Systems
  • Health Sciences › Nursing › Issues, ethics and legal aspects › Nursing Diagnosis and Documentation
  • Health Sciences › Health Professions › Health Information Management › Medical Coding and Health Information
Keywords
copy and paste, electronic health records, clinical documentation, documentation errors, patient safety, note templates, clinical decision support, critical thinking

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