Alarming Number of Doctors Copy EMR Progress Notes

Starting from the first day of kindergarten, schools teach children that copying is a definite no-no.  However, according to a new study, doctors seem to have forgotten this rule somewhere along the way as over half of intensive care unit physicians were shown to copy and paste information in patient progress notes in the hospital’s EMR system.

The Society of Critical Care Medicine conducted a study that analyzed 2,068 progress notes for 135 patients in an ICU, written by 62 residents and 11 attending physicians.  The study showed a disturbingly high occurrence of copied material in the notes, ranging from 20 to 61 percent.  82 percent of resident physicians copied information from previous progress notes and pasted it into a new one, all in the name of cutting corners to save time.  The attending physicians studied didn’t fare much better, as 74 percent of them were guilty of copying information.  Following at least one day off work, the percentage of attending physicians who copied information from their own prior notes increased to 94 percent. 

 Not only is the copying of EMR progress notes (information cloning) seen as immoral from a societal standpoint, but more importantly, this practice can also be very detrimental to the patient’s health and treatment.  Cutting and pasting medical data that’s a day old, or even a few hours old, can skip over and disregard pertinent information about the patient’s condition that occurred between the time when the physician saw them last, such as an event or changes in medication.   Information cloning can also lead hospitals and physicians to be investigated for insurance fraud if found to have consistent repeated diagnosis billing codes.  Medicare has vowed to crack down on record copying saying, “Identification of this type of documentation will lead to denial of services for lack of medical necessity and the recoupment of all overpayments made.”