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When information is copied and pasted into the ED chart, it can improve patient care because all providers are aware of the patient’s history — or it can legally compromise the entire medical record.
“The most important thing is to recognize that copying and pasting has both benefits and risks,” says Lorraine Possanza, DPM, JD, MBE, program director of the Partnership for Health IT Patient Safety, a collaborative convened by ECRI Institute. The collaborative developed safe practice recommendations for copy and paste in 2016 and an implementation guide in 2019.1,2
“Here we are in 2020, and the issue is still coming up constantly,” Possanza laments. “People need to know: This is something I’ve got to be paying attention to.”
These are some pitfalls for ED providers:
• The information pasted into the chart could lead providers to incorrect conclusions. The risk is the provider could mistakenly believe that a note taken from a visit years earlier that summarized a condition is describing the patient’s current condition.
“Knowing where the information came from is something to consider,” Possanza observes. “If the information was already copied from someplace else, though, it may get muddled.”
If the patient has been in the hospital recently, EPs can capture that history so it can be considered during the ED visit. Certain parts of a history do not change: the year a gallbladder or tonsils were removed or the age of the patient’s parents when they died. Similarly, a patient may have presented with a complex medical condition that requires a significant amount of associated care. A patient may have been undergoing chemotherapy for the past several months with many complications, and is now presenting to the ED for evaluation of a new complication. “That information can be best captured accurately and completely by copying it from another part of the record,” Possanza says.
Used in this manner, copy and paste is “time-saving, and allows you to capture a large amount of complex information,” Possanza adds.
If not noted correctly, though, it could be unclear to someone reading the chart later what was happening at the current encounter vs. a previous encounter. “This could lead to a billing problem, a compliance problem, or a treatment problem,” Possanza cautions.
If the patient returns to the ED with similar symptoms, pasting the history into the chart and letting it appear as though that is the current presentation “is not going to provide an accurate record,” Possanza says. “No one is going to report their symptoms in the exact same way both times.”
• EPs may copy and paste something, and inadvertently put it into the wrong patient’s chart. This will complicate the defense of any malpractice claim, regardless of whether it had anything to do with the bad outcome. “That impacts your credibility. Once you’ve lost your credibility, it’s very hard to get it back,” Possanza says.
“The legal defense issues for copy and paste come up when it casts doubt on the truth of the record. Then, the poison often spreads beyond one single note,” says Michael S. Victoroff, MD, a consultant on health IT in the department of patient safety and risk management at Denver-based COPIC.
The biggest lesson for EPs, says Possanza, is they need to copy and paste “discriminately.” Two questions need to be considered: Is this information important to include? How can the information be attributed to its original author?
If the EP documents “copied from January 2020 hospitalization” or “information from (date)” before the EP’s own documentation, there is no confusion. “It is important to add additional information, editing the copied material as needed, so that a complete picture of the current situation is in front of you,” Possanza says.
Catherine Vretta, MD, MPH, says it is common practice in emergency medicine to use copy and paste. “Problems arise when it is done without thought,” says Vretta, an EP at Ascension St. John Hospital in Detroit.
Not all patients warrant a complete physical exam. A patient with an isolated finger injury probably does not require a complete neurological exam. “When the same detailed physical exam is used repeatedly, it can certainly affect the validity of the entire chart,” Vretta says.
If other parts of the record also are copied and pasted, it makes the entire chart look suspicious. “A plaintiff’s attorney can then argue that everything is, by default, invalid,” Vretta explains.
Ideally, Vretta says EPs limit the amount of clinical information covered in a “normal” physical exam, and add pertinent positives or negatives as needed. “In this way, each exam will have some additional unique clinical information,” she reports.
This would help refute the plaintiff attorney’s assertion that every chart appears too similar. “It also helps to show the physician selected unique components of the particular patient and addressed them,” Vretta adds.
An EP may do everything right according to the standard of care. However, if the record shows notes copied from previous visits, “it calls into question whether the record reflects the patient interaction,” says Nathan A. Kottkamp, JD, a partner at Nashville-based Waller. Even if the patient presentation is similar to a previous ED visit, says Kottkamp, “it’s highly unlikely that circumstances will be identical. Therefore, the medical record should not be identical.”
The ED medical record serves as substantiation for billing for the services provided. “If the record doesn’t distinguish services provided from one visit to another, an insurance provider may reject the claim because of the lack of specificity,” Kottkamp explains.
Dean Sittig, PhD, says the most egregious errors involve copying information from Patient A to Patient B. “This can occur if, for example, an ED doc writes a beautiful note describing a particularly complex procedure — or even a simple procedure, for example, cleaning and suturing of a wound,” says Sittig, a professor in the School of Biomedical Informatics at the University of Texas Health Sciences Center in Houston.
The trouble starts when that EP sees a similar case. Rather than rewrite the entire note, the EP copies the note from the first patient’s chart and pastes it into the new patient’s chart. The EP intends to change all the pertinent details — right to left arm, his to her, 48-year-old to 19-year-old — but it never happens. “The problem arises when the doc misses one or more key elements, and something goes wrong, and the case goes to court,” Sittig says.
When the plaintiff’s expert or attorney sees this obvious mistake, it is easy to make the case the EP was careless and overworked. “It is difficult to defend those accusations,” Sittig says.
The same kind of copy and paste errors happen with frequent ED visitors. The EP decides to save time by copying the history and physical from a previous visit. “The ED doc forgets to change the date or specific issue,” Sittig says.
There are many valid reasons for the EP copying something from an old chart. “But one always has to be extremely careful when doing this,” Sittig cautions.
Financial Disclosure: The following individuals disclose that they have no consultant, stockholder, speaker’s bureau, research, or other financial relationships with companies having ties to this field of study: Arthur R. Derse, MD, JD, FACEP (Physician Editor), Michelle Myers Glower, MSN, BSN, RN, NEA-BC, CNEcl (Nurse Planner), Stacey Kusterbeck (Author), Jonathan Springston (Editor), Jill Drachenberg (Editor), Leslie Coplin (Editorial Group Manager), and Amy M. Johnson, MSN, RN, CPN (Accreditations Manager).