[Copy and paste in electronic health records]

Area of Science:

• Health Informatics
• Clinical Documentation
• Patient Safety

Background:

• Copy-paste (CP) functionality in electronic health records (EHRs) was adopted in the USA to improve clinical note efficiency.
• However, the use of CP in EHRs presents significant risks to patient safety and the integrity of medical documentation.
• Various American stakeholders have developed strategies to mitigate these documented challenges.

Purpose of the Study:

• To review the implications of copy-paste functionality in electronic health records.
• To examine existing strategies for managing CP risks in the USA.
• To assess the current status and potential future challenges of CP in Denmark.

Main Methods:

• Literature review of copy-paste practices in electronic health records.
• Analysis of stakeholder strategies in the United States.
• Comparative assessment of CP challenges in the US versus Denmark.

Main Results:

• Copy-paste in EHRs is a recognized issue in the USA, with established mitigation strategies.
• CP is not yet a significant concern in Denmark, but the potential for it to become one exists.
• Current Danish healthcare systems lack specific monitoring or counter-strategies for CP.

Conclusions:

• The widespread use of copy-paste in US EHRs highlights potential risks to patient safety and documentation quality.
• Denmark should proactively consider implementing measures to monitor and address the challenges associated with copy-paste functionality.
• Early consideration of CP risks can help maintain high standards of patient care and documentation integrity in Denmark.