You are a clinical data specialist in an ambulatory care facility that has a newly implemented electronic health record (EHR). You notice that certain clinicians are copying and pasting discharge summaries written by others from partner hospitals into their patients' records. You are concerned and write an "issues brief" for the next EHR steering committee. Which of the following points will you include in the issues brief?

Question

Quizplus · Accepted Answer

The issues brief should include all three points. A definition of copy/paste should be provided to ensure everyone is on the same page. The benefits and risks of copy/paste should be outlined to make the steering committee aware of the potential dangers of this practice, such as medical record inaccuracies and reduced quality of care. Medical record plagiarism should also be mentioned to emphasize the ethical implications of copying and pasting without proper attribution.

You Are a Clinical Data Specialist in an Ambulatory Care