For this discussion, you will be imagining you are a coder working in the Hathaway Hospital’s HIM Department. You have been asked to review physician documentation within the hospital’s new electronic health record system. The goal is to catch any documentation issues and work to correct them.

As you review the documentation, you notice that physicians are using a copy and paste function in the EHR that allows them to select record documentation from one source or section of the EHR and replicate it in another section. In one instance, you noticed that the patient was a 65-year-old male according to the history and physical but in the progress notes the physician has clearly copied documentation from another record as he notes the patient is a 25-year-old female who has given birth.

Share your thoughts on using copy and paste functionality in the EHR and how you might address this issue.