Re: [Gnumed-devel] copy and paste in emr

[Busser, Jim]

On 2012-05-28, at 11:13 PM, Sebastian Hilbert wrote:

http://www.medscape.org/viewarticle/763617_3

It is a good article.

For the benefit of those without a login, the above article used an illustrative case of a missed diagnosis. Hers was a case of pre-existing cancer which turned out to have been complicated by infective endocarditis.

The problem was that an MRI of the brain had been read as suspicious for "hemorrhagic metastases". Despite a note from the neurology attending expressing concern about a loud murmur and possible endocarditis, the term “hemorrhagic mets” appeared in the assessment and plan and was copied from note to note for the rest of the hospital course. The physical examination and imaging results from admission were also copied from note to note.

The patient died.

The article described the copying of someone else’s notes without attribution as especially dangerous and unprofessional and, in fact, a form of plagiarism. However, in my own view, even just the copying / pasting of one's own notes into a field intended to populate new information is a serious risk.

The article further points out the risks to document integrity posed by copying and pasting in the record as sufficiently serious to justify a recommendation by the American Health Information Management Association (AHIMA) that institutions audit note quality on a regular basis.

-- Jim