Cut-and-paste of text in the medical record has become easier with the introduction of the electronic medical record (EMR). Unfortunately, it can cause problems if done indiscriminately. A clinician may not have done anything wrong and yet still may be sanctioned.
Variations:
(1) cutting and pasting the same text documentation from day to day
(2) inclusion of a prefilled template
Reason for practice:
(1) saves time
(2) saves effort for someone not skilled as a typist
(3) reduces variability and standardizes documentation
(4) helps to meet increasing auditing requirements
Hazards of practice:
(1) fraud: claiming to have performed various services but did not
(2) misinformation with inclusion of data that is incorrect and potentially misleading if not caught by the author
Problems for the clinician can arise if:
(1) a scan of the documentation shows use of repetitive blocks of text
(2) there is evidence that the documentation does not match the patient's status or service delivered
(3) the time stamps, nursing notes or other evidence show discrepancies
Voice transcription may reduce effort but can potentially introduce errors if terms are misunderstood.
