Copied and pasted information in the ED chart might contain information that’s outdated or inaccurate, and can complicate the defense of a subsequent malpractice claim. To reduce risks:
- review all available data in patient records, and ensure that the information is up to date and accurate;
- establish standards for when this practice is prohibited, and when it may be used with extreme care;
- bear in mind that it’s particularly risky to copy vital signs with the intention of updating them with the current values.
An ED intern “copied and pasted” a preliminary report by a resident radiologist into his notes, giving the appearance that the intern actually had reviewed the images, with the attending EP signing the note.
“The final report by the attending radiologist was exactly opposite,” says Rodney K. Adams, LLM, JD, an attorney in the Richmond, VA, office of LeClairRyan. A resident’s concern about hemorrhage in the brain, which was vetoed by the attending, was followed by administration of tissue plasminogen activator. “The patient suffered a serious bleed later,” Adams says.
Legal problems can occur if information pulled into the electronic medical record (EMR) doesn’t match the chief complaint or the physical exam. “These plagiarized passages often contain information that is out of date or inaccurate,” Adams warns. “My favorite is a benign history and physical, followed by a treatment plan of intubation and admission to ICU.”
According to the Federation of State Medical Boards, “it is unethical and inappropriate to ‘copy and paste’ or otherwise document an entry that is not derived from a patient encounter at the time of the visit without indicating that the information is copied and pasted from another record.”1
A recent PIAA survey showed that more than half of member malpractice companies reported EMR-related malpractice cases. Copy and paste was the most common allegation, identified in 71% of cases.2
Incorrect copied-and-pasted information quickly complicates the defense of a subsequent malpractice claim. The plaintiff’s lawyer will contend one of two things, says Adams: “That the information should have put the EP on notice of the claimed issue, or that the EP never took a history or conducted the exam.”
Evidence of copying and pasting can help a plaintiff’s counsel discredit an EP during the course of litigation.
“Information from the EMR showing that the physician did not independently assess the patient — but, rather, copied and pasted other clinicians’ history and physical notes — reflects poorly on the physician,” says Graham Billingham, MD, FACEP, chief medical officer of Fort Wayne, IN-based MedPro Group.
This can make the EP’s defense an uphill battle. “Evidence presented from copied-and-pasted records may show clinical information that is inaccurate, no longer current, or incorrectly attributed to the patient,” Billingham explains.
In one case, a patient with a complicated medical history, including cancer, spinal problems, and a recent knee surgery, presented to a local ED with complaints of leg cramping. “The EP documented the patient’s immediate concerns, but failed to document a detailed medical history,” Billingham says. Instead, the EP opted to copy and paste the nurse’s written summary of her evaluation.
“Further, information from the patient’s chart that had been copied and pasted from previous medical visits within the same health system was accessed and replicated again during the ED visit,” Billingham says.
Ultimately, the patient required bilateral below-the-knee amputations, likely due to acute arterial occlusion. A malpractice lawsuit alleged delay in diagnosis. “The issue of the copy-and-pasted information in the patient’s record was used by the plaintiff’s counsel to cast doubt on the accuracy of the physician’s documentation and the quality of the care provided,” Billingham says.
He suggests EPs review all available data in patient records to ensure that the information is up to date and accurate.
“Because copy and paste is a top concern in EMR-related liability, healthcare organizations should establish standards for when this practice is prohibited, and when it may be used with extreme care,” Billingham adds.
Billingham says ED policies should align with hospital policies regarding copy and paste, and should emphasize these things:
- obtaining and documenting an independent history of the present illness;
- performing a physical exam and documenting the results;
- ensuring that the EMR contains adequate information related to the clinician’s medical decision-making.
Dean Sittig, PhD, professor in the School of Biomedical Informatics at the University of Texas Health Sciences Center in Houston, says it might be appropriate to copy and paste a long, complex, past medical history from a recent visit. “The key is that only accurate, historical information that cannot change should be copied,” Sittig recommends.
It is particularly risky to copy a patient’s vital signs with the intention of updating them with the current values. “Often, EPs forget to update a critical value,” Sittig says.
- Federation of State Medical Boards. Report of the Committee on Ethics and Professionalism in the Adoption and Use of Electronic Health Records, April 2014. Available at: .
- PIAA. Special feature: Part 2 of 2: Electronic health records in MPL. Research Notes, April 2016. Available at: .
- Rodney K. Adams, JD, LeClairRyan, Richmond, VA. Phone: (804) 343-4173. Fax: (804) 783-7637. Email: Rodney.Adams@leclairryan.com.
- Graham Billingham, MD, FACEP, Chief Medical Officer, MedPro Group, Ft. Wayne, IN. Phone: (800) 463-3776. Email: Graham.Billingham@medpro.com.
- Dean Sittig, PhD, Professor, School of Biomedical Informatics, The University of Texas Health Sciences Center, Houston. Phone: (713) 299-2692. Email: Dean.F.Sittig@uth.tmc.edu.