The advent of electronic medical records brought efficiency and a vast array of technical capabilities, including the popular “copy and paste” function, to the medical office. Copying and pasting is widely used by clinicians and is a convenient and time-saving way to export important and pertinent patient information from one section of the medical record to another. However, copying and pasting information has the potential to harm patients if not done prudently. One study of electronic medical records (EMR) indicated that pre-populating, copying, and pasting information represented the majority of medical record deficiencies.¹ From a professional liability standpoint, careless use of this popular function weakens potential defenses against medical malpractice claims, reflects poorly on the provider, and raises doubts as to the quality of the care provided.
The following scenario is based on a compilation of facts from various cases,2,3,4 and illustrates how copying and pasting outdated and unverified patient information led to a poor outcome. Unfortunately, there are many similar instances in which this documentation “shortcut” has led to preventable patient harm.
Dr. J was attending to a 65-year-old male patient, Mr. A, who had come in for removal of an ingrown toenail. During the procedure, Mr. A reported to Dr. J that he was also experiencing balance issues. Unfortunately, Dr. J was in a rush and decided to quickly copy and paste examination notes from another similar patient's EMR into Mr. A's record to save time. As a result, he omitted documenting Mr. A’s current balance issues.
A week later, Mr. A returned to the clinic for a routine post-procedure appointment. During the examination, Dr. J did not inquire about or address his balance issues because he relied on the previously copied and pasted notes which did not include this information. As Mr. A exited the exam room, he lost his balance and stumbled, causing him to fall and sustain a severe injury to his foot. The fall resulted in a fracture and required immediate surgical intervention to repair the damage. Mr. A was in significant pain and faced a long and arduous recovery.
Mr. A decided to file a lawsuit against Dr. J and the clinic, seeking compensation for medical expenses, pain and suffering, and any long-term effects caused by the fall. The lawsuit alleged that Dr. J failed to evaluate and treat his balance issues.
As the case progressed, the focus shifted to documentation practices. During Dr. J’s deposition,
it was revealed that he copied and pasted notes from another patient’s record, omitting Mr. A’s complaint of balance issues. Overall, these poor documentation practices created the impression that Dr. A was careless and unobservant with respect to his patient’s well-being and safety.
To prevent similar incidents in the future, Dr. J implemented the following changes in his practice:
Enhanced documentation review: Dr. J pledged to meticulously review and verify all copied information in patient records, ensuring accuracy and relevance.
Increased awareness: The incident prompted Dr. J to educate himself and his staff on the potential risks of copy and paste errors. This included the implementation of training programs and periodic reminders about the importance of accurate documentation.
There are several risk issues associated with copying and pasting in the patient medical record, including:
- Inaccurate or outdated information: If the original information was entered incorrectly or has since been updated, the copied information will not reflect the most current patient data.
- Cloning of information: Repeating the same content can create confusion and make it difficult to identify the most recent and relevant information.
- Lack of context: Without proper context, it may be difficult to accurately represent the patient's current condition or clinical reasoning behind the decision-making process. This can lead to misinterpretation or an incomplete understanding of the patient's medical history.
- Legal and compliance issues: Copying and pasting sensitive or protected health information may violate patient privacy laws and regulations if the information is shared or accessed by unauthorized individuals.
- Generic documentation: Documentation that is not customized or specific to an individual patient’s condition may negatively impact the quality of care provided, hinder continuity of care, and prevent effective communication among healthcare providers.
- Diagnostic errors: If copied information includes incorrect or outdated clinical findings, it can lead to diagnostic errors.
- Increased risk of medical errors: When incorrect information is copied and pasted, it increases the likelihood of errors and inaccurate treatment plans, compromising patient safety.
To mitigate these risks, physicians should establish clear policies and guidelines for appropriate use of copying and pasting in the medical record. Healthcare providers should be educated on potential risks and encouraged to critically review and update information before incorporating it into the patient's record. Regular audits and monitoring can help identify trends and proactively address issues. Below are related documentation principles that should be considered when creating documentation guidelines:
- Enable users to readily identify which text was copied and pasted.
- Make the origin date of the copied material available for reference.
- Monitor how copy and paste is being used in the practice setting.
- Consistently verify information in your note, especially information that is pasted or carried forward to ensure accuracy and internal consistency in the patient’s medical record.
Practicing sound copy and paste principles will promote safe and quality patient care, decrease risk, and prevent your documentation from becoming a distraction in the event of a professional liability claim. For additional guidance, consult the Toolkit for the Safe Use of Copy and Paste.5
Brad Dunkin, MHA, is Assistant Vice President, Risk Management and Patient Safety. Questions or comments related to this article should be directed to BDunkin@CAPphysicians.com.
Sources
¹Adam Schaffer. MD, “Clinical Documentation: It’s not just for revenue anymore,” Candello Webinar, February 13, 2024
²Case Study:Severe Consequences of Copy and Paste Documentation,
https://www.rmf.harvard.edu/Risk-Prevention-and-Education/Case-Study-Ca… (accessed 06/10/24)
³Case Study: Tripped Up by Copy and Pasting in the EHR,
https://www.rmf.harvard.edu/Risk-Prevention-and-Education/Case-Study-Ca… (accessed 06/10/24)
4The Perils of Copy and Paste,
https://www.linkedin.com/pulse/perils-copy-paste-bradley-truax (accessed 06/10/24)
5IT Safe Practices: Toolkit for the Safe Use of Copy and Paste PARTNERSHIP for Health IT Patient Safety. ECRI. 2016. https://www.ecri.org/Resources/HIT/CP_Toolkit/Toolkit_CopyPaste_final.p… (accessed May 8, 2024)