Are copy/paste functions used in EHR documentation prohibited?

This resource is part of the AMA's Debunking Regulatory Myths series, supporting AMA's practice transformation efforts to provide physicians and their care teams with resources to reduce guesswork and administrative burdens.

There is no federal regulation prohibiting the use of the copy and paste function (CPF) within the electronic health record (EHR). 

CPF, also called copy functionality, copy and paste, cloning, and carry/copy forward, involves selecting (copying) and reproducing (pasting) all or part of a previous note in the EHR to a new entry, then making any necessary modifications to ensure accuracy and relevance.^1,2 Most major EHR systems enable this function, allowing for the easy transfer of information that doesn’t change between entries.^2,3 

Some organizations may restrict the use of CPF in the EHR intending to mitigate a perceived risk associated with it (e.g., inadvertent use of information which may no longer be accurate or potentiation of information that never was accurate). Overuse of CPF can also lead to note bloat by including irrelevant information from previous notes.² However, if used with proper care, this function can help decrease documentation time and effort, reducing the need for re-entry of previously documented information. 

Regardless of the method used to document information, it is ultimately the responsibility of the treating physician to ensure its accuracy and completeness.

Several regulatory agencies and accrediting bodies including the Centers for Medicare & Medicaid (CMS)¹, The Joint Commission⁴, and the Office of the Inspector General (OIG)⁵ have provided guidance on best practices for the use of CPF. According to best practices, organizations should consider:

• Educating and training staff on (1) ensuring copied-pasted information is reflective of the service provided in the current encounter; and (2) avoiding inappropriate use of CPF (e.g., copied signatures, different charts, and unread information);
• Establishing mechanisms that enable easy identification of copied/pasted information and its source, such as leveraging staff and EHR functionalities to cite, highlight, or use a distinct font for copied, unedited data; and
• Regularly evaluating CPF-use to assess whether utilization meets relevant standards and identify opportunities for improvement.^1-4

Copy and paste functions can be valuable time-saving tools if used properly. Health care organizations should establish training and guidance for EHR users on the appropriate use of CPF, and users should consistently ensure copied/pasted information is accurate, up-to-date, relevant to the current encounter, and in compliance with any pertinent organizational policies.

• 2016 CMS Decision Table for Ensuring Proper Use of EHR Features. Accessed February 2025.
• 2016 Partnership for Health IT Patient Safety Copy and Paste Toolkit. Accessed February 2025.
• 2021 The Joint Commission Guidance on Preventing Copy-and-Paste Errors in EHRs. Accessed February 2025.
• 2013 OIG Report on Medicare Hospitals’ Implementation of Recommended Fraud Safeguard in the EHR. Accessed February 2025.
• AMA News Article: Copy, Paste, Repeat: Widespread EHR Practice Could undermine Care. Accessed February 2025. 
• AMA Journal of Ethics Article: Copying and Pasting Patient Treatment Notes. Accessed February 2025. 

• The CMS Electronic Medical Records Initiative Should Not Be Used To Detect Alleged Fraud by Physicians D-175.985

1. Centers for Medicare & Medicaid Services (CMS). Ensuring Proper Use of Electronic Health Record Features and Capabilities: A Decision Table. Published online June 28, 2016. Accessed February 4, 2025. https://www.cms.gov/files/document/ehrdecisiontable062816pdf
2. The Joint Commission. Quick Safety 10: Preventing Copy-and-Paste Errors in EHRs. The Joint Commission. July 2021. Accessed February 4, 2025. https://www.jointcommission.org/resources/news-and-multimedia/newsletters/newsletters/quick-safety/quick-safety--issue-10-preventing-copy-and-paste-errors-in-ehrs/preventing-copyandpaste-errors-in-ehrs/
3. Levinson DR. Not All Recommended Fraud Safeguards Have Been Implemented in Hospital EHR Technology. Office of the Inspector General (OIG); 2013. Accessed February 4, 2025. https://oig.hhs.gov/oei/reports/oei-01-11-00570.pdf
4. Partnership for Health IT Patient Safety. Health IT Safe Practices: Toolkit for the Safe Use of Copy and Paste.; 2016. Accessed February 4, 2025. https://d84vr99712pyz.cloudfront.net/p/pdf/hit-partnership/copy-paste-toolkit.pdf
5. Al Bahrani B, Medhi I. Copy-Pasting in Patients’ Electronic Medical Records (EMRs): Use Judiciously and With Caution. Cureus. 15(6):e40486. doi:10.7759/cureus.40486

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Disclaimer: The AMA's Debunking Regulatory Myths (DRM) series is intended to convey general information only, based on guidance issued by applicable regulatory agencies, and not to provide legal advice or opinions. The contents within DRM should not be construed as, and should not be relied upon for, legal advice in any particular circumstance or fact situation. An attorney should be contacted for advice on specific legal issues. Additionally, all applicable laws and accreditation standards should be considered when applying information to your own practice.