Between "Hangovers," Bradley Cooper starred in a largely forgettable melodrama called "The Words." The main character was an aspiring writer whose career first skyrockets and then implodes when he plagiarizes an entire novel from a dusty manuscript found buried in an old briefcase bought at an antique store. As art, "The Words" is destined for the on-demand scrap heap, but it may yet be redeemed as a cautionary tale for anyone who creates electronic health records.
While EHRs have many advantages that can improve health care delivery, including easy access and portability, the same technology that affords these advantages can also promote careless practices that may call into question the accuracy of the entire record and make it difficult, if not impossible, for health care providers to defend themselves in court. Among the most troublesome EHR misuses we see in litigation is the inappropriate use of copy and paste functions, whereby a health care provider "plagiarizes" his/her own or a colleague’s prior documentation.
In medical negligence claims, the accuracy of the patient’s medical record and the credibility of the health care providers are often both at issue, and many times the two go hand in hand. Lawyers representing injured patients love to point out errors in the medical record, whether or not the error caused any patient harm, because – the argument goes – if the medical provider was careless in record-keeping, then chances are he/she was also careless in the treatment at issue. So too, if the jury is provided with facts that differ from the medical record, suspicion arises. Thus, an innocent but preoccupied provider is accused of lying or of trying to cover up a treatment error. To avoid these insinuations, clinicians must put time and effort, as well as original thought, into medical record documentation.
Our experience in reviewing medical records for litigation suggests that a surprising number of practitioners routinely copy and paste information from a prior entry in the EHR. The excuses we have heard for this run the gamut from unfamiliarity with the electronic system to lack of time and, ironically, the need to ensure accurate documentation. Similarly, in "The Words," when Bradley Cooper’s character starts copying another author’s manuscript – word for word – onto his laptop, he tells himself that he is doing it simply for inspiration. Excuses aside, this kind of rote replication is seductively easy but fraught with danger, particularly if the EHR later comes under scrutiny.
Next page: Consequences of plagiarism >>