The Dangers Of Copy-And-Paste In Your Medical Records
With the seemingly endless amount of information clinicians are required to enter into medical records software each day, it comes as no surprise that doctors and other hospital staff are looking for short-cuts to reduce their documentation burden. At our customers, we’ve seen copying and pasting of data from templates or other patient records to reduce the burden. We’ve seen drop down lists that contain hundreds of items, and to simplify their lives clinicians just choose the first item on the list so they can move on to the next step. A new study by the University of California San Francisco, and published by the American Medical Association, confirms that clinicians are frequently opting for short-cuts when it comes to entering data into electronic medical records.
The study, which examined over 20,000 notes across 460 caregivers, found that 46% of notes were copied and pasted, 36% were imported, and just 12% were entered manually. While the documentation burden on clinicians is too high, the copy and paste solution being utilized to reduce the burden is dangerous for patients and leads to extra work for other clinicians. As this article by Mike Miliard at Healthcare IT News discusses:
“For all the benefits brought about by electronic health records, it’s long been known that they have their pitfalls, whether it’s ungainly user experience or agita caused by alert fatigue.
Another major risk for EHRs is the temptation toward “note bloat” caused by caregivers’ easy ability to copy-and-paste data from other parts of the chart. This defeats the purpose of electronic documentation, of course, creating a large and unwieldy record that can be hard to make sense of – potentially putting patient safety at risk…
“The traditional goal of progress notes is to provide a concise, up-to-date reflection of the patient’s condition and the clinician’s thought process,” said UCSF researchers. “However, copying or importing text increases the risk of including outdated, inaccurate, or unnecessary information, which can undermine the utility of notes and lead to a clinical error.”
Read the entire article here: EHRs are overflowing with copy-and-paste records, JAMA study shows
It is up to healthcare providers to arm their staff with the necessary tools to provide both excellent patient care and accurate and complete documentation of their encounters. There are many ways that hospitals can reduce the temptation to simply copy-and-paste the problem away – implementing data entry efficiency tools to complement EHR software seems to top the list. Natural language processing technologies will help by offering real-time transcription for clinical documentation. Automated data capture systems, such as iRISupply, can also provide high quality data by integrating RFID data capture technology directly into your EMR.