Electronic medical records were meant to help the medical community stay up-to-date on their patients’ medical history but a habit shared by many doctors who use electronic medical records may be putting patient safety at risk.
More doctors are starting to copy and paste old, out-of-date medical information into patients’ electronic medical records, according to a study published in Critical Care Medicine. The study found that this behavior could lead to more medical errors caused by miscommunication.
Electronic medical records allow health care providers to share a patient’s medical history and keep the medical staff treating the patient well-informed about his or her medical condition.
Unfortunately, the time-saving shortcut that allows doctors to copy and paste text from previous medical documents has been found to cause confusion and miscommunication between medical staff members. The study found that this type of miscommunication can often lead to medical errors that could potentially harm the patient.
A typical document that is shared among doctors, nurses and other staff members are progress notes. These notes usually track the patient’s treatment and what tests have been performed. The study said that progress notes were very likely to be one of the documents subjected to being copied by doctors and pasted into a patient’s electronic record.
The study found that 82 percent of hospital residents’ progress notes and 74 percent of attending physicians’ notes had more than 20 percent of copied and pasted text from a patient’s previous medical record.
Researchers said that when doctors copy and paste previous notes into a patient’s record, there is a risk of miscommunication between medical staff because they may not know the current treatment or condition of the patient since the notes were not accurately updated.
This miscommunication of the patient’s condition can lead to medical errors that could really harm the patient. Despite the best intentions of having doctors use electronic medical records, future studies may show that doctors’ behavior and inability to update these records may lead to more patients being harmed.
Source: Money Control, “Copying common in electronic medical records: study,” Jan. 8, 2013
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