Content Patient Information. Healthcare information content requirements for are presented in Tables 3 and 4. They are organized by content that be” and be” copied/pasted within “can “cannot various records of the same patient within the visit (Table 3) and across the visits (Table 4). Content examples from the AHIMA 2012 Toolkit are shown by the asterisk*, from the NISTIR 8166 by – double asterisk **. 3. Patient Information: Content Requirements for Copy/Paste Within the Same Visit Content HIM Actions Information that CAN BE copied/pasted The following are examples of content that may be copied if – the information has been verified and validated and has remained the same over a specified time period Demographics* Reviewed, updated & verified at every visit Medications* Reviewed, updated & verified at every visit Allergies* Reviewed, updated & verified at every visit Problems* Reviewed, updated & verified at every visit Elements of a History* (past Reviewed, updated & verified at every visit medical, social and family history) Test Results (laboratory, imaging, Encounter-specific; Reviewed, updated & verified at every visit etc.)* Physiology Studies Encounter-specific; Reviewed, updated & verified at every visit Review of Systems Encounter-specific; Reviewed, updated & verified at every visit Discharge Summary** Specific elements may be copied, e.g., reason for admission, medications Elements of Care Plan (Quick Notes, Encounter-specific; Reviewed, updated & verified at every visit Consults, Specialty Notes such as Neurology, Cardiology, etc.) Information that SHALL NOT BE copied/pasted The following content should never be copied and – pasted Vital signs* Assessment* New test result** New test result that is expected in a few days should never be populated with the old one from the earlier record Authorizations** Consent Anesthesia records** Do not resuscitate (DNR) wishes of the patient Living Will (LW) Any documentation not specific Discuss with SME to the admission, e.g., The review and update of copied/pasted information should be documented by: Describing any new information or Noting there has been no change in the information and Noting the source, date and author of the earlier information.
Content Patient Information. Healthcare information content requirements for are presented in Tables 3 and 4. They are organized by content that “can be” and “cannot be” copied/pasted within various records of the same patient within the visit (Table 3) and across the visits (Table 4). Content examples from the AHIMA 2012 Toolkit are shown by the asterisk*, from the NISTIR 8166 – by double asterisk **. 3. Patient Information: Content Requirements for Copy/Paste Within the Same Visit Content HIM Actions Information that CAN BE copied/pasted – The following are examples of content that may be copied if the information has been verified and validated and has remained the same over a specified time period Demographics* Reviewed, updated & verified at every visit Medications* Reviewed, updated & verified at every visit Allergies* Reviewed, updated & verified at every visit Problems* Reviewed, updated & verified at every visit Elements of a History* (past medical, social and family history) Reviewed, updated & verified at every visit Test Results (laboratory, imaging, etc.)* Encounter-specific; Reviewed, updated & verified at every visit Physiology Studies Encounter-specific; Reviewed, updated & verified at every visit Review of Systems Encounter-specific; Reviewed, updated & verified at every visit Discharge Summary** Specific elements may be copied, e.g., reason for admission, medications Elements of Care Plan (Quick Notes, Consults, Specialty Notes such as Neurology, Cardiology, etc.) Encounter-specific; Reviewed, updated & verified at every visit Information that SHALL NOT BE copied/pasted – The following content should never be copied and pasted Vital signs* Assessment* New test result** New test result that is expected in a few days should never be populated with the old one from the earlier record Authorizations** Consent Anesthesia records** Do not resuscitate (DNR) wishes of the patient Living Will (LW) Any documentation not specific to the admission, e.g., Discuss with SME The review and update of copied/pasted information should be documented by: Describing any new information or Noting there has been no change in the information and Noting the source, date and author of the earlier information.
AHIMAUseCase_CopyPaste-05-10-17.docx