Health Information Management

Q&A: Taking a stand on medical record copy and paste functionality

CDI Strategies, January 8, 2015

Want to receive articles like this one in your inbox? Subscribe to CDI Strategies!

Q: What is ACDIS’ stance on physicians cutting and pasting the entire radiology report into their progress note? Are we allowed to take diagnoses from this documentation? Can the physician cut and paste the radiological findings from the report into their progress notes? Or is this, in both instances, just a good query opportunity?

A: If I had my way the copy/paste function would be turned off (and I have heard a few organizations doing just that) but I am not the one making the rules. Now, my answer is not going to be clearly black and white.

If the provider includes an MRI interpretation, or even the latest lab result,s but also offers a summary or interpretation of his or her own, a query may not be necessary. The statement can even be as simple as: “I agree with the radiologist’s finding of,” or “these lab results support the diagnosis of.”

But, if the findings or results simply pasted into the medical record without any explanation then the CDI team should query to clarify. I earned my CDI chops at the elbows of some very conservative coders and know they would wish for more distinct clarification from the provider.

That said, organizations interpret this practice differently. Ask your coding supervisor or manager to better understand your organization’s policies around the electronic medical record, specifically the cut and paste functionality. Consistency within the organization is important, and the CDI team should be aware of any such policies to communicate those back out to the medical staff during regular, ongoing education.

Additionally, ACDIS did publish a position paper “Electronic health records and the role of the CDI specialist,” in its October 2013 edition of the CDI Journal.

Hope this helps!

Editor’s Note: Laurie L. Prescott, MSN, RN, CCDS, CDIP, is a CDI Education Specialist with HCPro Inc., in Danvers, Mass., and a lead instructor for its CDI-related Boot Camps. For more information regarding upcoming Boot Camp dates and locations visit

Want to receive articles like this one in your inbox? Subscribe to CDI Strategies!

    Briefings on APCs
  • Briefings on APCs

    Worried about the complexities of the new rules under OPPS and APCs? Briefings on APCs helps you understand the new rules...

  • HIM Briefings

    Guiding Health Information Management professionals through the continuously changing field of medical records and toward a...

  • Briefings on Coding Compliance Strategies

    Submitting improper Medicare documentation can lead to denial of fees, payback, fines, and increased diligence from payers...

  • The No-Hassle Guide to EHR Policies, 2nd Edition

    This second edition from EHR expert Margret Amatayakul provides the tools you need to develop effective HIPAA-compliant EHR...

  • Leverage the Value of your EHR

    This 90-minute audio conference helps your organization leverage additional value from your EHR to not only meet your...

Most Popular