An epidemic is sweeping the country, and no one is doing anything about it. No it’s not Zika virus.
The epidemic I’m talking about is the widespread use of “copy and paste” in medical progress notes.
How widespread is it?
A 2009 study from Cornell surveyed faculty residents from two academic medical centers and found that 90% of the physicians who wrote inpatient notes electronically used copy and paste in their progress notes. Most of them acknowledged “that inconsistencies and outdated information were more common in notes containing copy and pasted text,” but fewer than 25% thought that using copy and paste was detrimental to documentation or caused errors in patient care.
My anecdotal experience is that 90% is an underestimate.
Using copy and paste can be detrimental. I have said before that it doesn’t matter what is written in a chart unless something goes wrong.
“…90% of the physicians who wrote inpatient notes electronically used copy and paste in their progress notes”
Progress notes in electronic records are cluttered enough without adding material that was in previous notes word for word. An even bigger problem is the extensive use of copy and paste raises issues of credibility.
In a progress note, a patient was described as “alert and oriented X 3” because that’s what that the notes from the three previous days said. A few lines further down in the same note the physical examination said the patient was “intubated, sedated, and on mechanical ventilation.”
Another note said, “The patient appears well nourished” because that appeared every day for the last week. Later on in the note, an attending physician stated in the plan for the day, “He is malnourished. Will start tube feedings.”
If I were a plaintiff’s lawyer, I would ask the doctors who wrote those notes to explain the contradictions. If nothing else, the authors of such notes look foolish. However at worst, they make one wonder if anything stated in their progress notes really happened. A jury might be convinced to doubt anything the doctors say on the witness stand.
The use of copy and paste in notes also has implications for billing. We have all seen notes listing a 10-point review of systems supposedly done every day complete with the same typos in exactly the same place in every note.
The ECRI Institute’s Partnership for Health IT Patient Safety convened a working group consisting of a number of physicians and information technology experts to address the subject of copying and pasting notes. A 58-page report of its findings was published in February 2016.
Here is what they recommended that healthcare organizations should do:
Provide a mechanism to make copy and paste material easily identifiable.
Ensure that the provenance of copy and paste material is readily available.
Ensure adequate staff training and education regarding the appropriate and safe use of copy and paste.
Ensure that copy and paste practices are regularly monitored, measured, and assessed.
I have some doubts about these recommendations. For example, the ECRI group says that hospitals should ensure that a note’s provenance is documented thusly: “Identify the original source (date, time, record, and author) of the information to verify accuracy, applicability, reliability, and timeliness.”
For a couple hundred inpatients? I don’t see that happening anytime soon.
Wouldn’t it be simpler just to tell doctors that copying and pasting is not allowed?
Skeptical Scalpel is a retired surgeon and was a surgical department chairman and residency program director for many years. He is board-certified in general surgery and a surgical sub-specialty and has re-certified in both several times. For the last six years, he has been blogging at SkepticalScalpel.blogspot.com and tweeting as @SkepticScalpel. His blog has had more than 2,500,000 page views, and he has over 15,500 followers on Twitter.