Many physicians use a copy-and-paste tool for daily clinical documentation. Until now, the general rule offered to hospitalists in the literature has been to document only what is accurate. This advice, while obvious and sound, doesn't help hospitalists in daily practice. Following are clinical examples to illustrate problems resulting from improper use of copy-and-paste and practical instruction in how to improve documentation in the electronic medical record (EMR).
The reputation of today's EMR, tainted by copy-and-paste-related errors, has decayed to the point that the daily progress note—once regarded as the “go to” part of the medical record to find a concise and reliable summary of the patient's current status—is now often ignored. This lost reliability may lead to patient harm, loss of trust between physician colleagues and nurses, inappropriate billing, and increased utilization of resources. It also forces hospitalists to invest time to verify information in more reliable parts of the EMR. Consider the following scenarios:
- A hemodialysis patient is admitted with pneumonia. The hospitalist states in the progress note “...will continue treatment with cefepime and vanco.” The sputum culture later grows only Pseudomonas, and therefore vancomycin is discontinued, but the progress note, reflecting copy-and-paste, remains unchanged. The patient then develops a new fever, and repeat blood cultures show preliminary growth of gram-positive cocci. A covering hospitalist is alerted to the newly positive cultures, reads in the progress note's plan “...will continue treatment with cefepime and vanco,” and determines that no additional antibiotics are needed. The cultures ultimately grow methicillin-resistant Staphylococcus aureus. Unfortunately, the infected dialysis catheter that caused the fever has now progressed to bacteremia.
- An ED physician verbally informs a hospitalist that their patient being admitted received antibiotics in the ED. Later, the hospitalist discovers it was a different patient in the ED who received those antibiotics, which irreversibly damages that ED physician's credibility in the opinion of the hospitalist. Now consider how much more damage to credibility occurs when the misinformation is in the form of written progress notes, as can happen when copy-and-paste errors are inadvertently entered in the EMR. How can decisions about patient care be made with confidence when they are based on information in the progress notes that is feared to be inaccurate or unreliable?
- A nurse reads in a hospitalist's progress note on sequential days “patient's pressure ulcer is draining foul-smelling, purulent discharge.” In reality, however, the ulcer has markedly improved after antibiotics and persistent dressing changes, so now there is no drainage or odor. What will this nurse think about this hospitalist who entered those notes? Is this hospitalist unable to appreciate the improvement of the wound (incompetent), or is the wound not being examined each day despite daily documentation of the wound's appearance (fraudulent)? Is the hospitalist unaware of what is written in the notes (careless), or is the wound being examined and its improvement appreciated, but the hospitalist isn't bothering to correct the discrepancies in the note (lazy)? All of these reasonable conclusions damage this hospitalist's reputation.
- A hospitalist orders an echocardiogram for a patient recently admitted with an acute myocardial infarction and writes in the note “patient needs an echocardiogram.” The next morning, the same hospitalist rounds and leaves the progress note unchanged, since the echocardiogram will not be performed until later that afternoon. The following day, the weekend hospitalist reads in the note, “patient needs an echocardiogram.” Believing that the echocardiogram has not been pursued, he orders the echocardiogram. This duplicate echocardiogram is then completed on Monday morning before the error is recognized.
- A hospitalist performs a physical examination on a patient being admitted with lower extremity cellulitis, and as part of the exam, the patient's pupillary responses are checked and documented. Using copy-and-paste, the entire admission physical exam was carried forward and appeared in each subsequent progress note, with the hospitalist making daily changes to the documentation concerning the lower extremity. As is typical and appropriate, however, the pupillary exam was not repeated each day, despite being documented as such. If that element of the physical exam was used to meet a higher level of billing, the note could be considered fraudulent.
In my opinion, these negative consequences caused by errors in copy-and-paste documentation are completely preventable. Here are 10 techniques that can redeem EMR documentation.
1. Do not use “I”.
When a physician writes “I” in a note, all other physicians who use that note must edit it to keep the note accurate. For example, “Code status was discussed with Mr. Smith and he requested to be DNR” will always be true regardless of the author, whereas “I discussed code status with Mr. Smith and he requested to be DNR” is true for only one documenting physician.
2. Include specific dates.
Use of “today,” “tomorrow,” or “yesterday” limits the note to being true for one day only and needs editing to remain accurate on all other days. A note written to state a specific date, such as “heparin was stopped 2/20 due to bleeding,” will be true every day.
Likewise, writing “ID consult recommends ceftriaxone for 6 more days” requires changing the note every day to remain accurate. Instead, write “ID consult recommends ceftriaxone through 2/26.” Documenting in this way requires no editing in subsequent notes and preserves useful and time-saving information in the note for future clinicians.
3. Use the past tense.
The present and future tenses require editing for the note to remain accurate when used for copy-and-paste. For example, if the statement “patient's neuro status remains stable, therefore will discontinue neuro checks” is copied and pasted into the next day's note, any reader may conclude the patient has been getting neuro checks up through that same day.
Instead, the author should write “neuro checks discontinued due to stable neuro status on 2/24.” This statement correctly informs the reader that the neuro checks have stopped, and adding a specific date tells exactly when.
4. Delete the prior history of present illness (HPI).
When a new HPI is added to each day's progress note without deleting the prior HPI, the note becomes a running log of HPIs and is excessively long and cumbersome. If information from a prior HPI is ever needed, it easily can be retrieved from the EMR.
5. Delete the prior review of systems (ROS).
Intra-note contradictions often occur when a running log of ROS is kept in the progress note or when the ROS from admission is carried forward into the progress note. If the note has separate HPI and ROS, the HPI may be edited each day, whereas the ROS may be left unchanged.
This can result, for example, in a note with an HPI that states “patient is nauseated” while the ROS within the same note states “patient denies nausea.” Any pertinent symptom belongs in the HPI, and an extensive ROS is not helpful and is not needed for billing. Deleting the ROS will make notes more concise and internally consistent.
6. Document the physical exam actually performed each day.
Review the documented physical exam every day to ensure no elements are included that weren't actually examined. For example, it is unlikely for the tympanic membranes inspection or proprioception testing to be performed again after the admission physical, so be sure they do not appear in the progress notes each day due to copying and pasting. Again, it would be difficult to believe that those elements were examined each day, resulting in loss of credibility.
7. Delete routine daily labs and vital signs.
Keep the progress notes concise by not including all routine lab results or vital signs in the notes. When these are needed, they are easily found in the appropriate location in the EMR.
8. Do not use “pending” when referring to consults.
If “cardiology consult pending” appears in the note, it will need editing after the consultation is performed. Instead, writing “cardiology consult requested at 3 p.m. on 2/22,” is accurate and additionally provides a legal safeguard. If the patient suffers an adverse outcome due to a delay in the consultation, the precise time the consult was requested will be evident in the note, and the fact that it was documented before the adverse event occurred will be more credible than any statement the consultant later makes about the timing of the consult request.
9. Use “pending” when referring to tests and cultures.
Write in the note that an important test or culture is pending on the day it is ordered, such as “nuclear stress test ordered 2/28—pending” or “blood cx obtained 2/25—pending.” This will serve as a reminder for the rounding physician that a test result or culture needs follow-up.
As long as the test is still pending, the note does not need editing and can be repeated using copy-and-paste each day. When the result does become available, simply replace the word “pending” with the test result. This technique provides a built-in signout by ensuring that no test or culture is forgotten and that no test is duplicated.
10. Maintain the problem list throughout the hospitalization.
It is helpful to keep the problem list updated with issues as they arise during the hospitalization, even after they have resolved. For example, a patient developed rapid atrial fibrillation after his admission and was given 3 doses of metoprolol with no effect, followed by 1 dose of diltiazem resulting in a slower heart rate and conversion to normal sinus rhythm. Several days later, with a different rounding hospitalist, the patient developed rapid atrial fibrillation again.
The hospitalist looked to the latest progress note, and saw “Problem #7: PAF—patient developed rapid AF on 2/19, was given metoprolol with no effect, but converted to sinus after a single dose of diltiazem.”
This brief notation quickly informed the hospitalist of several helpful facts, saved the time of looking through prior notes, and suggested the most appropriate course of action. Also, having this notation carry through each progress note using copy-and-paste until the last day of hospitalization ensured that it was included in the discharge summary.
Many serious problems and potentially permanent harm to patient health and physician credibility can result from copy-and-paste misuse. By using the 10 techniques described in this article, I believe any hospitalist team can quickly redeem the reputation of their EMR and of copy-and-paste documentation by producing concise and reliable clinical records that improve patient safety, hospitalist credibility, and quality of care.