Copying and pasting of examinations within the electronic medical record

Abstract

Electronic patient records often include text that has been copied and pasted from other records. A type of copying that involves the highest risk for confusion, medical error, and medico-legal harm is the copying of the clinical examination. We studied this phenomenon using an automated text categorization algorithm to detect copied exams in a set of 167,076 VA records. Exam copying occurred frequently, in about 3% of all exams, or in 25% of patient charts. Thirteen percent of all authors had copied at least one exam, and 3% of authors had copied an exam from another author. There were significant differences between service types and levels of training of the authors. We speculate that copying and pasting of exams degrades the quality of the medical record, and that studying this behavior is integral to our understanding of phenomenology of the electronic medical record.