Yup, that’s the new legal buzzword for medical lawsuits. It’s called “electronic plagiarism”. Remember how the EHR or EMR was going to save us so much time? Well, we all know how that turned out. Unfortunately, with all the extra clicks it has become too easy or all too common for doctors to take the easy road “cut and paste”. This is a nice article explaining why we need to be more reserved in doing this. Here are some excerpts:
- In medical negligence claims, the accuracy of the patient’s medical record and the credibility of the health care providers are often both at issue, and many times the two go hand in hand.
- Lawyers representing injured patients love to point out errors in the medical record, whether or not the error caused any patient harm, because – the argument goes – if the medical provider was careless in record-keeping, then chances are he/she was also careless in the treatment at issue. So too, if the jury is provided with facts that differ from the medical record, suspicion arises. Thus, an innocent but preoccupied provider is accused of lying or of trying to cover up a treatment error.
- Our experience in reviewing medical records for litigation suggests that a surprising number of practitioners routinely copy and paste information from a prior entry in the EHR.
- Copying can result in entering outdated or inaccurate information into the patient’s chart. Even simple errors of this kind can be very damaging.
- 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 bottom line is that beware of the EHR succubus. It seems easy but will get you in trouble in the end. That doesn’t answer the question of how to keep up with your work without “copy and pasting”. And, by the way, “quick texting” can get you in the same trouble. How many times have you clicked in that shortcut key for a complete physical and forgot you used a male template on a woman? It is embarrassing to see that her testicles showed no masses, right? I have no answer to make this job quicker other than doing it in a place where you have the proper time to actually put all the information in the right spots and tie up all loose ends. That is not Wonderland. The only job that does that is Direct Primary Care. 🙂