Several years ago, while performing chart reviews in a post-acute care center, I came across a nurse’s note that was amazing. The note went into great detail, how the resident was doing, complete vital signs, the resident’s appetite, bowel status, hydration, etc. I was so impressed that I talked to the nurse and told her “great job”! Later that day, reviewing another chart, I found the same entry (different vital signs) and lo and behold, that same entry was in every chart I reviewed! I wondered, could it be that every one of these residents had a good appetite, moved their bowels, were hydrated, etc.? Likely not.

Circle back to square one, educating this nurse on the concern with this type of “copy and paste” entry. Sure, these were handwritten notes and not “literally” copy and pasted however, the outcome is the same. Under scrutiny, these entries would be questioned, if this nurse were deposed, would she be able to defend her entries? Likely not. Now bring on the electronic record, the copy and paste option, the autofill option, yikes! Another concern with EHRs, late entries. Yep, entries flagging as “late” are always questionable even if legitimate.

Bottom line, tread cautiously, get your nose in the charts, see what is happening on a day-to-day basis. Consider off-site chart accessibility, are your docs documenting from home at midnight? Think of the errors that are just waiting to happen with this practice not to mention the “late entry” flag? Maybe remote access should be set as “read only”? Talk to your EHR provider, ask the questions, at the end of the day it is your responsibility to know what is happening and why. Audit a sample number of entries a week and discuss your findings with the QAPI committee. You do NOT have to be a nurse to identify when an entry is late or “copy and pasted”. Trust me, if a plaintiff attorney can identify these things, you can too! Stay well and stay informed!