Copy-paste is one of the most useful functions available to users of any electronic documentation system. Clinicians use electronic health records (EHRs) to document the details of a healthcare encounter. Such details include the symptoms that the patient is reporting, physical exam, test results, diagnosis, assessment, and treatment plans. When the patient’s problem is recurrent or chronic, the clinician needs to document updates on the same problem on a repeated basis.
In order to increase efficiency, the clinician may use copy-paste to bring forward portions of the documentation from one record to the next.
While copy-paste is a convenient tool for busy clinicians, it can lead to inaccurate, misleading, and potentially dangerous errors in the EHR. This article will focus on the clinical pitfalls of inappropriate copy-paste.
The main problem is that information that was once accurate becomes inaccurate if it is not updated to reflect the patient’s current status. With copy-paste, it is all too easy to propagate information and neglect to update it.
For example, consider the following description of a patient hospitalized for pneumonia who develops swelling of the left leg on the third day of the hospital course. The attending physician orders an ultrasound to determine if the leg swelling is due to a deep venous thrombosis (blood clot). The brief summary at the end of the physician’s note includes the description of the patient’s pneumonia treatment as well as the following statement:
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“Left leg swelling. Venous doppler ultrasound ordered.”
Later that day, the physician learns that the ultrasound is negative.
The following day, in order to save time, she uses the copy-paste function and inserts the same summary statement from the previous day into the note. But she neglects to update the note with the ultrasound results.
Since she didn’t update the information, the record is now outdated, and therefore inaccurate. It states that the ultrasound status is “ordered” but the ultrasound has actually been performed and the results known.
Outdated, inaccurate medical records can affect patient safety, especially when other clinicians (specialists, consultants) rely on the note to keep up to date with progress of the patient. The potential for error is multiplied if the inaccurate information is propagated throughout the patient’s record in the EHR and other connected health information systems.
This problem can occur in inpatient and outpatient records. In a study of 135 patients in an intensive care unit, 82% of notes created by resident physicians (in training) and 74% of notes created by attending physicians (fully trained) contained at least 20% copied information in the section containing the assessment and plan.
Another disadvantage of copy-paste is that discourages clinicians from exercising critical thinking skills in analyzing, summarizing, and communicating the patient’s status in progress notes. With copy-paste, progress notes can easily become bloated with extraneous, outdated information while obscuring the most important details about a patient’s status.
The American Health Information Management Association recommends that “The use of copy/paste functionality in EHRs should be permitted only in the presence of strong technical and administrative controls which include organizational policies and procedures, requirements for participation in user training and education, and ongoing monitoring.”
While copy-paste may increase efficiency in certain circumstances, the benefits need to be weighed against the potential for creating outdated, inaccurate, and unnecessarily lengthy documentation in the EHR.
The American Health Information Management Association.
Appropriate Use of the Copy and Paste Functionality in Electronic Health Records. Accessed on June 29, 2014.
Thornton JD, Schold JD, Venkateshaiah L, Lander B. Prevalence of copied information by attendings and residents in critical care progress notes. Crit Care Med. 2013 Feb;41(2):382-8. doi: 10.1097/CCM.0b013e3182711a1c. Accessed on June 29, 2014.