Clinical Copy-Paste

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

Careless copy-paste behaviours can degrade the chart while contributing to errors:

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. 

Connect Care has tools that allow users to quickly recognize which parts, and how much, of a note have been copied:


Any copy-out (copy from the Connect Care clinical information system [CIS] to a separate information system) must be done with extreme caution, as there is risk of a privacy breach. This practice is strongly discouraged. If appropriate and required, the needed information should be exported or printed (to pdf) so that text is not separated from character and formatting encoding. The copy-out content, time and destination should be documented in the Connect Care chart for audit purposes.


Within System

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. Any copied material should be revised to reflect significant change to the current state. The origin of copied information must be attributed, acknowledging the original context in which the copied information was generated.

Between Systems

Copy-paste of clinical content from one health information system (e.g., Community Electronic Medical Record, Netcare, etc.) to another system (e.g., Connect Care) is not appropriate and should not be done. There are a number of dangers:

If there are sound clinical reasons for copying clinical content between systems, it may be acceptable to export a fully formatted (pdf) document from the source system for attachment to the destination Connect Care chart (Media Manager). This explicitly tags the information as coming from an external system. The external document workflow includes protections against the dangers listed above.

It may be acceptable to copy a discrete data element, such as a unique identifier, for pasting to a search function in a destination system. This would not constitute copy-paste of clinical documentation.

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