When it comes to patient records, doctors guilty of the old copy-paste

Ah, the old copy/paste. Such a handy keyboard shortcut for such a wide range of applications. But would you want your doctor using it while maintaining your oh-so-personal and unique-to-you medical records?

More than 80 percent of observed residents’ notes in medical records included copied information.

(Credit: Screenshot by Topher Kessler)

Because chances are good that your doc does, according to new research out of Case Western Reserve University School of Medicine. Excuse me while I take a moment to summarize, rather than copy and paste, some key findings from the research.

Assistant professor of medicine and lead author Daryl Thornton and his team scrutinized 2,068 electronic patient progress reports at an ICU in Cleveland. Some 62 residents and 11 attending physicians had their gloved hands in these documents over the course of five months as they updated the files of 135 patients.

Thanks to software typically used to detect plagiarism, the researchers found that 82 percent of residents’ notes and 74 percent of attending physicians’ notes contained material that had been copied from previous records or other documents. And the offending “material” was not just a phrase or two; at least 20 percent of the records had been inserted from elsewhere.

While the copying behavior may range from harmless timesaving to the insertion of downright erroneous information, the researchers readily admit that they set out to find prevalence of copying and did not delve into why the physicians did this or what effect, if any, this behavior has on actual patient care.

When it comes to patient records, doctors guilty of the old copy-paste