Page 23 - Hospitalists - Risks When You're the Doctor in the House (Part Two)

SVMIC Hospitalists - Risks When You’re the Doctor in the House

Copy and Paste

The copy and paste function creates the capability to produce

a note by using a previously-documented assessment. While
there may be clinical reasons for a hospitalist to review earlier

notes in order to determine whether or not symptoms have
resolved or worsened, the use of a copy and paste capability to

create the new note from the old note is fraught with potential
for problems. Copying information from a prior note and

pasting into a new note can result in notes which are identical
for multiple encounters. This is particularly risky for a physical

examination which may have changed since a prior encounter
and now may not reflect the complexity in the patient’s

condition. Using this function may also result in irrelevant over-
documentation perpetuating outdated or incorrect information

and produce voluminous progress notes that obscure important
new information. Copying and pasting entire x-ray reports or lab

data into notes only adds to the problem. It can also result in
entries with errors that are repeated in multiple notes, essentially

becoming “immortalized”. In other words, the mistakes that were
made in prior entries are carried forward. This is particularly

apparent in typos and non-standard abbreviations that are
carried forward from the initial entry.

Auto-Population

Auto-population, like templates, allows the EHR system to
prefill information in specific areas of the medical record as

a means of creating a shortcut or improving the efficiency of
the documentation process. The practitioner must be aware of

those areas of the medical record that are auto-populated in
order to know what information will need to be reviewed and

either verified or corrected prior to signing the note.

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