As a legal nurse consultant, you are in an ideal position to detect copying and pasting in medical records.
This is what you might see: A staff nurse copies the note she wrote the previous day. Or she copies the note written by the previous shift. The attending physician copies a progress note he wrote the previous day when he examined the hospitalized patient. A nurse practitioner copies a note from the prior office visit. This innocuous seeming practice can result in confusion, embarrassment, misinformation and medical errors.
ECRI Institute and Copying and Pasting in Medical Records
Recent studies focused on the drawbacks of electronic medical records. Both identified copying and pasting in medical records as the source of errors. ECRI Institute compiles a database of patient safety events.
With more than 300,000 event reports, ECRI is in an ideal position to spot trends. One of the top 10 concerns is data integrity failures with health information technology systems – errors caused by electronic medical records.
ECRI points out that the integrity of data in health IT systems can be compromised by copying and pasting in medical records by putting older information into a new report. Other sources of errors include
- Data entry errors
- Missing or delayed data delivery
- Inappropriate use of default values
- Use of both paper and electronic systems for patient care (hybrid records)
- Patient/data association errors (patient data from a medical device is mistakenly associated with another patient’s record)
An insurance company called CRICO collected data in a large database of 275,000 open and closed claims. In a study released in 2014, it found 147 cases in which electronic health records were a contributing factor. These were the top issues:
- Incorrect information in the electronic health record in 20% of cases
- Hybrid health records/EHR conversion issues in 16%
- Systems failure – electronic routing of data in 12%
- Pre-populating/copy and paste in 10%
- Failure of system design to meet the need in 9%
- EHR (user) training and/or education in 7%
- Lack of integration/incompatible systems in 7%
- EHR-related user error (other than data entry) in 7%
You need a critical eye when evaluating medical records. The attorney relies on you to read the record and see if it makes sense. Copying and pasting in medical records is easily detected when it refers to events, like surgery, as taking place in the future, when they have already occurred. It is also easily detected when page after page of nursing notes are identical or there is obvious erroneous information in the record. It is harder to detect when there are scattered pieces that were duplicated that could possibly be correct.
Always read records carefully, putting together the whole picture of the patient. Question information that does not seem right.
It just may be that the staff were taking a shortcut. The attorney relies on you as a legal nurse consultant to point out potential problems and weak spots that could be caused by copying and pasting in medical records.
Pat Iyer MSN RN LNCCC is president of The Pat Iyer Group. She has reviewed thousands of medical records. Watch this on demand webinar: Electronic Health Records: Are They Safe?