“Sloppy and paste” charting in electronic medical records is dangerous for patients.

A recent study in Critical Care Medicine found that physicians and residents often used the cut and paste feature to more quickly chart patient notes into the electronic health records (EHR) system.

You can read a review of the study from the Washington Academy of Family Physicians website here:

[“Sloppy and paste” endures despite patient safety risk][1]

The study found that 82% of all residents’ and 74% of all attending notes contained at least 20% copied information. Doctors and residents argue that without copying and pasting, there is simply not enough time to chart on patients.

But copying and pasting also has the potential to cause serious harm to patients. The article relates a story about a patient who was supposed to get an anticoagulant medication, and the chart note stated the patient “would” receive it. Unfortunately, the same chart note was copied and pasted four days in a row, the woman was discharged without getting the medication, and was later re-hospitalized after suffering a life threatening pulmonary embolism.

In our own practice, it is common for us to review records that show the same language in successive chart notes.

It’s unclear whether physicians need more time to responsibly chart, or the system somehow needs fixing to prevent this problem. What is clear is that patients can suffer serious harm when “sloppy and paste” occurs.

[1]: http://wafp.net/News/News/02-13/%E2%80%9CSloppy-and-paste%E2%80%9D-Endures-Des.aspx ““Sloppy and paste” endures despite patient safety risk”