The use of electronic health records has made it much easier for doctors to access patient medical records and get a more complete picture of their health data. HealthIT.gov notes that one benefit is that medical professionals can create and share the records across organizations, including laboratories, imaging facilities, pharmacies, clinics and hospitals. As a result, every medical professional involved in a patient’s care may access and add to the records as needed.
These records are only helpful if they are accurate, though.
According to the American Medical Association, a problem that can affect care and lead to problems for physicians is the copying and pasting of notes in charts.
Researchers point out that patient records may reach epic proportions if they include every single note from every visit. This volume of notes may be impossible for a doctor to review before attending to each patient. Also, it may make it difficult to determine who included the note, why the provider included it, why there may be repetition and what to infer from a lack of updates.
In addition, doctors are spending nearly half their workdays on data entry, and only 27% of their time actually seeing patients. The benefits of moving text rather than creating new may seem to outweigh perceived risk.
In one study, though, the researchers discovered that only 18% of the notes in the typical medical record were original, manually entered text. Copied and pasted text made up about 46% of the records, and medical professionals had imported 36% of the text from other sources, such as vital signs data or test results.
When data include errors, copying and pasting can have disastrous results. It may be difficult to discern who originally entered the error, and how long it has been in the record. As EHR technology improves, it may become much easier for physicians to capture an accurate picture of patient information and identify mistakes. Until then, copying and pasting may cause problems for the physician that relies on others to be error-free.