Back to the Case
Upon recognizing the discrepancy regarding which knee was replaced, you issue an addendum to your initial note. You forward this addendum to the resident who had copied large parts of your note with a gentle reminder regarding the perils of copying and pasting. Although the patient in this case suffered no harm from the cutting and pasting of medical documentation, that may not be true the next time.
Jane S. Kang, MD, is an assistant professor of medicine and program director of the Rheumatology Fellowship at Columbia University Medical Center/New York Presbyterian in New York. She is completing a Masters of Bioethics at Columbia University.
Robert H. Shmerling, MD, is the clinical chief of rheumatology at Beth Israel Deaconess Medical Center in Boston and the chair of the ACR’s Committee on Ethics and Conflict of Interest.
Editor’s Note
If you have comments or questions about this case, or if you have a case that you’d like to see in Ethics Forum, e-mail us at [email protected].
References
- Hammond KW, Helbig ST, Benson CC, et al. Are electronic medical records trustworthy? Observations on copying, pasting and duplication. AMIA Annu Symp Proc. 2003;269–273.
- Weir CR, Hurdle JF, Felgar MA, et al. Direct text entry in electronic progress notes. An evaluation of input errors. Methods Inf Med. 2003;42(1):61–67.
- O’Donnell HC, Kaushal R, Barron Y, et al. Physicians’ attitudes towards copy and pasting in electronic note writing. J Gen Intern Med. 2009 Jan;24(1):63–68.
- Thornton DJ, Schold JD, Venkateshaiah L, et al. The prevalence of copied information by attendings and residents in critical care progress notes. Crit Care Med. 2013 Feb;41(2):382–388.
- Letter from Obama administration on hospital billing. The New York Times. 2012 Sep 24.
- AMA Code of Medical Ethics. Opinion 9.132—Health Care Fraud and Abuse.
- Adler-Milstein J, Jha AK. No evidence found that hospitals are using new electronic health records to increase Medicare reimbursements. Health Aff. 2014 Jul;33(7):1271–1277.
