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/policies/administrative/uw-health-administrative/health-information-management/647.policy

201606153

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UWHC,UWMF,

Policies,Administrative,UW Health Administrative,Health Information Management

Data Replication Policy (6.47)

Data Replication Policy (6.47) - Policies, Administrative, UW Health Administrative, Health Information Management

6.47

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Administrative (Non-Clinical) Policy
This administrative policy applies to the operations and staff of the University of Wisconsin Hospitals and
Clinics Authority (UWHCA) as integrated effective July 1, 2015, including the legacy operations and
staff of University of Wisconsin Hospital and Clinics (UWHC) and University of Wisconsin Medical
Foundation (UWMF).
Policy Title: Data Replication Policy
Policy Number: 6.47
Effective Date: June 1, 2016
Chapter: Health Information Management
Version: Revision

I. PURPOSE

The purpose of this policy is to establish parameters for the use of various methods of data replication
within the electronic medical record (EMR), including copy/paste, copy forward, cloning and any other
method used to replicate documentation from one section of the medical record to another. The
appropriate use of templates and copy-paste functionality can reduce time spent documenting while still
providing pertinent information about an episode of care. However, indiscriminate use frequently leads to
lengthy, unreadable notes that contain duplicative, outdated, and/or inaccurate information. This adds to
the complexity of patient care by making information retrieval more difficult. Furthermore, from a billing
perspective, inappropriate use of templates and copy functionality could result in the submission of a
claim for services not actually provided.

II. DEFINITIONS

Clinician Author: A clinical staff member who has the authority and responsibility for creating and/or
authenticating patient health record entries. Examples include: Physicians, Advance Practice Nurses,
Certified Nurse Midwives, Physician’s Assistants, Psychologists, Pharmacists, Speech Language
Pathologists, Audiologists, Licensed Clinical Social Workers, and any other health care professional
licensed, credentialed, and/or approved by UW Health to document in the patient health record. Clinician
Author also includes residents and students in approved health occupation programs under the supervision
of a clinical staff member. It is also recognized that others besides Clinician Authors may assist in the
documentation process, but they do not have final responsibility for the documentation; this responsibility
is assigned to the author who finalizes or authenticates the patient health record entry.

III. POLICY

Clinician Authors documenting in the medical record should avoid indiscriminately copying and pasting
notes and duplicating redundant information provided in other parts of the EMR. It is incumbent upon the
individual Clinician Author to ensure the accuracy of his/her note, whether it contains original text or
contains information copied from another source.





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IV. PROCEDURE
A. Clinician Authors are required to document in compliance with all federal and state laws, UW
Health policies (including University of Wisconsin Hospital and Clinics (UWHC) policies,
University of Wisconsin Medical Foundation (UWMF) policies), UWHC Medical Staff Rules
and Regulations, and all applicable regulatory requirements.
B. Clinician Authors are legally responsible for the total content of their documentation, whether the
content is original, copied, pasted, imported, reused, or otherwise replicated from other sections
of the EMR.
C. The Clinician Author’s signature shall serve as attestation that the information is accurate and that
any replicated information is current and represents the Clinician Author’s services for that date
of service.
D. If information is copied or reused from a prior note, the Clinician Author is responsible for its
accuracy and medical necessity.
1. Replicated information must be reaffirmed and revised as necessary to accurately reflect
the date of service.
2. Information must not be replicated if it does not specifically impact the current date of
service.
3. Information replicated from the note of another Clinician Author, or one created at
another facility, must be referenced to include date, time and author of the original entry.
a) Refer to Copy Paste Techniques in Health Link regarding copying and pasting
information from an outside organization.
E. The following data replication is specifically prohibited:
1. Copying information from one patient’s note to another patient’s record.
2. Copying information entered by students.
a) Refer to Copy Paste Techniques in Health Link for information about adding a
link to medical student documentation of Review of Systems and Past, Family, or
Social portion of history for Evaluation and Management Services.
F. Clinician Authors are encouraged to cite and/or summarize applicable lab data, pathology, and
radiology reports rather than replicate these reports in their entirety.
1. Any replicated information must be attributed to the original source/author.
2. The date of the original report must be referenced.
G. Clinician Authors are responsible for correcting any errors in their documentation as detailed in
the UW Health Link Chart Corrections Guidelines available on U-Connect.
1. If the note needing correction/revision is already signed/finalized, the correction will be
made via an amendment as outlined in UW Health Policy 6.14-Amendment of the
Medical Record.
H. The use of data replication functionalities may be audited and findings of noncompliance will be
forwarded to appropriate leadership.
V. COORDINATION

Sr. Management Sponsor: UW Health Chief Information Officer
Author: UW Health Director, Health Information Management
Reviewer: University Hospital Compliance Officer; Professional Services Compliance Officer

Approval Committee(s): Medical Record Committee; UW Health Administrative Policy and Procedure
Committee




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SIGNED BY

Ronald Sliwinski
President University Hospitals
Chief of Clinical Operations


Revision Detail:

Previous revision: 072013
Next revision: 072019