The medical record is no doubt, a very valuable document that contains information about a patient’s medical history and the various clinical interactions. In medical litigation, they are a valuable mine of information giving the attorney the medical facts they want in the case. These facts are unearthed during the detailed medical record review for attorneys provided by a medical record review company. Apart from being clinically significant, the medical record is a legal document that serves as evidence of the care provided. This is why a medical chart that is created appropriately at the time of the patient encounter, and properly maintained becomes very important when it comes to successfully defending a medical malpractice lawsuit. It is mandatory that medical records are highly accurate and comprehensible. They need to be contemporaneous and should not be tampered with or modified inappropriately.
Medical record integrity is an absolute must. So, the recent copy-paste tendency among physicians using electronic health records has become a real concern, not only for patients whose safety is compromised but also for attorneys handling medical malpractice cases who have to mine medical records for copied material. When the physician copy-pastes electronic text in patient documents, any errors that were already there are brought forth into the other records or new errors may be created. EHRs come with templates to enter patient information. The entries made must be updated for each patient at the appropriate time. However, with the push towards electronic medical records and the requirement to provide comprehensive documentation for medical billing purposes, more and more physicians are copy-pasting details, which may ultimately land them in real trouble. The medical record is a legal document and when following a medical record review it is found that the physician had indulged in copy-pasting, it may not go well for him/her.
According to recent studies, incorrect information is found to be a very common clinician related contributing factor in malpractice cases associated with EHRs. The problem with copy-pasting information is that physicians may fail to edit the record to signify the current situation. The record may often refer to something that happened at a previous date and if it is not updated in keeping with the patient’s condition it can put the physician at the risk of medical malpractice. For instance, take the case of an entry “The patient presented to the ED with severe abdominal pain yesterday,” and imagine the case if this is copy-pasted over a period of one or two weeks without correcting the “yesterday”! Rampant errors in the electronic medical records compromise their reliability and make it impossible for judges to reach a definitive conclusion.
Unfortunately, a common EHR concern such as copy and paste throws doubt on the physician’s as well as the medical record’s reliability. The doctor may not be guilty of malpractice, but issues such as this in the patient’s medical record can put him/her in an unfavorable light before a jury or judge.