by SkepticalScalpel | Mar 15, 2016
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 Most of them acknowledged “that inconsistencies and outdated information were more common in notes containing copy and pasted text,” but fewer than 25% thought that using copy and paste was detrimental to documentation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,...
