When data from a prior note in the EHR are copied, little thought or focus is given to context or clarity, and the cobbled-together entry is frequently disorganized and unclear. Worse yet, such copying can result in entering outdated or inaccurate information into the patient’s chart. Even simple errors of this kind can be very damaging. Imagine trying to convince a jury that you are a careful and caring practitioner when it has been pointed out to them that, in your records, your patient’s blood pressure was exactly the same every time she was in your office over the last 5 years. Or that despite the fact that she was experiencing a precipitous, unexplained weight loss, you continued to describe her as morbidly obese. Or that even though her husband died 3 years ago, your records show her "accompanied by spouse" at every visit.
Sometimes EHR plagiarism goes right to the heart of the negligence claim. Where the claim is inappropriate discharge of a patient who died a few days after leaving the hospital, the defense must show that the patient’s condition improved and that troubling symptoms seen on admission responded appropriately to treatment. This effort is hampered by documentation prepared many days or weeks into a hospitalization that copies symptoms and physical findings that are no longer present. Inaccurate information in the EHR can also confuse other medical providers, and the time necessary to reconcile inconsistent information may delay treatment. Likewise, if inaccurate information is relied on for treatment decisions, the results can be disastrous.
It is often argued in litigation that if something doesn’t appear in the medical record it didn’t happen. A corollary to this dubious "rule" is that once bad information is documented in a medical record, it will be redocumented over and over and over again. Predictably, the more times the erroneous data are repeated in the EHR, the more "reliable" it becomes. This problem has been around a long time, but EHR plagiarism has made it worse.
The medical record is the most important evidence in any medical negligence case. While it is true that only a small fraction of medical records will ever see the inside of a courtroom, you should always document assuming the chart in front of you could end up there. This requires time, original thought, accuracy, and completeness. Copying and pasting the electronic medical record, while superficially efficient, is the enemy of these goals, and could leave you – like Bradley Cooper in "The Words" – wondering what happened to your promising career.
Ms. Kane and Mr. Balaguer are in private practice in Wilmington, Del. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. He is also editor-in-chief of Redi-Reference Inc., a software company that creates mobile apps.