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The Role of Copy-and-Paste in the Hospital Electronic Health Record

Ann M. Sheehy, MD, MS1; Daniel J. Weissburg, JD, CHC2; Shannon M. Dean, MD3
[+] Author Affiliations
1Division of Hospital Medicine, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison
2University of Wisconsin Hospital and Clinics, Madison
3Division of Pediatric Hospital Medicine, Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison
JAMA Intern Med. 2014;174(8):1217-1218. doi:10.1001/jamainternmed.2014.2110.
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Before electronic health records: If you did not document it, you did not do it.

After electronic health records: You documented it, but did you do it?

After a slow start, hospitals in the United States have rapidly adopted electronic health records, as encouraged by the Health Information Technology for Economic and Clinical Health Act of 2009 (HITECH).1 By May 2013, more than 3800 hospitals, or about 80% of the hospitals that were eligible, had received incentive payments from the Centers for Medicare & Medicaid Services (CMS) related to the adoption, implementation, upgrading, or “meaningful use” of these records.2 Yet the application of electronic health records can be a double-edged sword. Their use can increase efficiency, facilitate information sharing, standardize hospital processes, and improve patient care1,3,4 But their use can also have unintended consequences and be subject to abuse, such as when data are duplicated or templates and checkboxes are used to generate standardized text without a good medical reason.

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The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
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Submit a Comment
Too much copy and paste
Posted on June 3, 2014
Art Scherer MD
VAMC Spokane
Conflict of Interest: None Declared
Reading a copy and paste note in a chart is often a slow and useless affair. Only the beginning, stating the patients SX and signs,new or changed tests or images,etc, and the end of the note stating what conclusions are drawn and what the provider intends to do about it, are enlightening. In between are paragraphs, and sometime pages, of old copy and pasted data. This is a shame. Slowing down the transfer of the real useful information. Personally I just never copy and paste. Try it. You might like it. And your colleagues will love it!
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