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.
Careless copy-paste behaviours can degrade the chart while contributing to errors:
Pasted material may preserve inaccurate or outdated information, adversely affecting current clinical decisions.
Confusion about authorship can obscure accountability and frustrate correction of error.
Copied material tends to grow with each reproduction, incrementally increasing note length and chart clutter.
Copied material can propagate false information.
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 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.
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.