Many doctors copy and paste old information into patients' electronic health records, according to a recent study published in the journal Critical Care Medicine, Reuters reports.
For the study, Daryl Thornton -- assistant professor at Case Western Reserve University School of Medicine -- and colleagues examined 2,068 electronic patient progress reports created by 62 residents and 11 attending physicians working in the intensive care unit of a Cleveland hospital.
The researchers then used plagiarism-detection software to analyze the progress notes for 135 patients over a five-month period.
Using the plagiarism-detection software, the researchers found that:
- 82% of progress notes created by medical residents contained 20% or more of copied and pasted material from patient records; and
- 74% of progress notes created by attending physicians contained 20% or more of copied and pasted material from patient records (Stokes, Reuters, 1/4).
Concerns About Copying and Pasting Patient Information
According to EHR Intelligence, copying and pasting patient information could be particularly risky in an ICU, where small changes to a patient's treatment plan could affect his or her condition. Copying and pasting data also could lead to:
- Patient records containing outdated or inaccurate information;
- Incorrect or fraudulent billing requests; and
- Federal audits for suspicious activity (Bresnick, EHR Intelligence, 1/7).
Unrelated Editorial Warns Against Copying and Pasting Patient Data
In an unrelated editorial published in the Journal of Urology, Deborah Erickson -- a professor of surgery at the University of Kentucky College of Medicine -- wrote that repeatedly copying and pasting large portions of patient information could result in "a long, rambling note that does not make clear points."
Erickson added, "It is much better for each day's note to synthesize and interpret the prior data, leaving out old information that is no longer relevant" (Reuters, 1/4).