The electronic health record offers numerous advantages over its paper counterpart: the ability to access a chart from any location; the opportunity for multiple viewers to read or contribute to a chart simultaneously; legibility; and the ease of incorporation of data into the note, without transcription error. Electronic charting is not without its pitfalls, however. Typing progress notes can be cumbersome, especially if data are not accessed easily while composing the note. Free terminals might be unavailable, and notes can disappear with the wrong click of a mouse.
Information specialists have attempted to design electronic records in a way that eases use and supports decision making.(1, 2) Computerized physician order entry is an example of a technology that generally has been viewed favorably but is not without its perils.(3, 4, 5, 6) Charting would seem to be a simpler issue, largely focusing on simplicity for the user and data capture for the extractor. But unlike computerized physician order entry, where all share the goal of ordering the correct medication at the correct dosage, documentation reflects the training and perspective of the professional who is recording the data.
One of the most egregious dangers of electronic charting lies not in a deficiency but in a feature, the copy-and-paste function, which allows an author to copy information from a prior note and paste it into a new note. Although physicians generally fail to perceive its negative impact,(7) the copy-and-paste function has led to a number of unexpected problems and concerns about electronic note writing(8, 9) and its impact on the culture of medicine,10 including reducing the credibility of the recorded findings, clouding clinical thinking, limiting proper coding, and robbing the chart of its narrative flow and function.
To learn more about the hazards of “copy and paste,” read this article in its entirety on our website.
— Eugenia L. Siegler, MD, Ronald Adelman, MD
This article was originally published in the June 2009 issue of The American Journal of Medicine.
