Clinical Copy-Paste

Good clinical documentation is concise and unique. A well-organized electronic record allows brevity because information can be referenced and linked, not copied. Clinical notes can be interpretive, not repetitive, exposing the meaning of data stored in other sections of the record.

In general, copy-paste is not needed and should not be used. It is always better to reference original content and highlight changes occurring since.


Any copy-out (copy from Connect Care CIS to a separate information system) must be done with extreme caution, as there is risk of a privacy breach.


CIS users who copy-paste for convenience (e.g., as a template for the next note) should verify that all copied information remains correct, pertinent and relevant. The origin of copied information must be attributed, acknowledging the original context in which the copied information was generated.