time to several hours (often depending on contractual times or
To this end, copy and paste is still a huge challenge in the industry, says Terri Costa, RHIA, CMT, director of HIM and quality
at Betty Ford Center.
“;ere is potential for records to get clogged up with the same
information multiple times, and there is always the inherent
risk of someone copying an error and then duplicating the error
throughout the chart,” she says.
Costa recommends a strict copy and paste policy in conjunction with ongoing physician and sta; education.
;e use of e-mail and texting brings its own set of documentation challenges for HIM professionals.
While securing e-mail and text messages may be a top priority
for organizations, there are other peripheral concerns, such as
the use of protected health information. Organizations should
outline policies and procedures and conduct sta; training on the
proper use of protected health information in e-mail communication between provider and patient or provider and provider.
E-mail and text messages
require a documented retention
policy and schedule.
In addition, a well-de;ned process must exist for archiving
messages, including a documented retention policy and schedule. Consideration should be given to scenarios where changes
are made to the patient’s treatment plan as a result of an e-mail.
All information entered in the health record should enable
triggers for work;ows and alerts according to standard organizational protocol. Using copy and paste to document e-mail
content in the EHR may not yield the same work;ow results and
places data quality at risk.
;e use of texting in healthcare documentation is getting a lot
of attention. According to a recent survey of College of Healthcare Information Management Executives, 97 percent of those
surveyed allowed physicians to text orders to their nursing sta;
and 58 percent said they do not use encryption software. 2 ;ere
are privacy and security concerns within this situation due to
the lack of encryption, and use of texting language in the health
record carries an increased threat to documentation integrity.
Policy and procedure should address all aspects of text usage, including how text information is transcribed from the text
message into the EHR with emphasis on providing complete
information. Text documentation should contain professional
language with no abbreviations or cryptic language for the receiver to interpret.
Clear documentation standards and proper work;ows are the
key to ensuring providers document information that is pertinent, timely, and accurate. It is imperative for HIM professionals to educate, implement, and monitor the data capture and
documentation requirements. ¢
1. ASTM International. ASTM E 2117-06 Standard Guide for
Identi;cation and Establishment of a Quality Assurance
Program for Medical Transcription. West Conshohocken,
2. Dolan, Pamela. “Physician Texting Provides Quick Communication—and an Easy Way to Violate HIPAA.” October 31, 2011. www.ama-assn.org/amednews/2011/10/31/
AHIMA. “Copy Functionality Toolkit.” 2008. Available in the
AHIMA Body of Knowledge at www.ahima.org.
Julie A. Dooling ( firstname.lastname@example.org) is a director of professional practice at AHIMA.