I hadn’t given a lot of thought to how patients having electronic access to their health records would affect my practice as a physician assistant who treats infectious diseases. I certainly wasn’t opposed to letting patients see all their test results and the notes written by the various specialists who get involved with them. Our hospital is one of several in Ontario that have adopted a patient portal for access to their own records, and fundamentally, I agree that this information belongs to the patient. I thought perhaps I should be more aware of using terms like “morbid obesity” and “looks older than stated age,” but I didn’t think the impact on my day-to-day note-writing would be significant.
I was wrong.
A few months ago, we were consulted about a young female Asian Canadian with non-small-cell lung cancer, which unfortunately had already metastasized. She was undergoing chemotherapy to try to slow down the cancer’s progression, and I was seeing her because she had come to hospital with a fever. The patient’s very-worried husband and their teenage children were often with the patient when I saw her on the ward. Fortunately, other than the fever, she seemed stable, and I enjoyed our interactions.
There’s a familiar adage in medicine that goes: “If you didn’t document it, it didn’t happen.” It reminds us of the importance of keeping an accurate record of each patient encounter. I recently chuckled when I came across a tweet that re-invented this line for a 2018-electronic-medical-record universe: “If you didn’t cut and paste it from another note, it didn’t happen.” In my hospital, the patient’s entire chart is available on my computer, from their vital signs and lab results to the ED notes and consult notes. Which makes it very easy for me to go to the notes done by other physicians, nurse practitioners or physician assistants, and just start to cut and paste bits and pieces of those notes while I build my own. Does it save me time? Absolutely. And many patients hate being asked the same questions about their illness or drinking habits or travel history numerous times during the same admission. Have I sometimes copied something from another provider’s note that turned out to be erroneous, or not quite the whole story? Sure, but these details can often be corrected in the notes going forward, and they’re usually minor.
On the third day after I’d met the young woman with lung cancer, her husband followed me into the hallway after I left the room. He very gently told me that he’d been reading the notes in his wife’s electronic chart and saw that I had written, under the heading “Social History,” that although the patient had never been a smoker, her husband was a smoker. Smoking history is an important detail for almost all patients admitted to hospital, but in a patient with lung cancer, it can be a clue as to the possible causes of the cancer. And indeed, I had cut and pasted that detail about my patient’s husband from another consult note written by someone else. (I could see it had been copied into a few other—although not all—notes in her chart.) I didn’t double-check the information with the patient or her husband.
The problem is, it wasn’t true. Neither the patient nor her husband had ever been smokers. And it disturbed this poor man to think that we somehow might be blaming him for his wife’s terminal disease. As it should. As he pointed out, his wife’s ethnic background put her at higher risk of genetic mutations that are known to be associated with lung cancer in non-smokers. He was not angry, but in his place, I might have been. He knew that I didn’t invent the mistake—I was just the first person whose name he remembered who had repeated it, and I seemed like someone who might help him set the record straight.
How did I react? I was mortified. I apologized. I took responsibility for my laziness (let’s face it, that’s what it was) in not verifying that information before I allowed it to continue to be part of his wife’s health record. I assured him that I would correct this detail going forward, and hoped he wouldn’t see it in anyone’s notes again. Fortunately, he accepted my apology, our interactions after that were entirely comfortable, and the patient was discharged home within a few days.
This encounter has made me a more careful historian and documentarian. It’s not that I don’t still cut and paste some details. I do. I try to double-check the history that is relevant to my involvement with the patient, and if it isn’t relevant, I now leave it out altogether. And whatever I paste, write, or dictate, I pause and consider that among the many people who will read my note in the future, some of them may be the very people at the centre of this whole encounter. And I damn well better at least try to have the facts right.
The author has been granted permission by the patient and her family to tell this story.
The comments section is closed.
Hello Maureen,
Thanks for sharing this story and owning the mistake, albeit like you said, you were not the person that created the error in the first place. It is appreciated. There is a lesson there for all of us.
A patient in my clinic was denied life insurance because of an erroneous fact in the social history in their chart.
Upon further investigation, it was apparent that the reason was not due to copy / paste, but due to identity theft – someone else had used a fraudulent health care card to obtain health care, and this information was included in the patient’s chart.
We informed the life insurance company. They refused to overturn their denial.
The consequences of incorrect chart notes – regardless of whether the etiology was copy / paste error, human error, or identity theft – can be extremely serious.
Well done Dr. Taylor for being willing to help others learn from this situation.
That’s terrible Dr. Moore, and while it might be too late to correct this issue for this patient, there IS a Provincial Insurance Regulator who deals with these problems for consumers. They are absolutely great. The link, just in case. :)
http://www.fsco.gov.on.ca/en/insurance/Pages/default.aspx
Excellent article. For years, before patient portals, I have been sending out copies of my consult notes to patients so that they can know what I said, and I have had the opportunity to correct my errors. I had one colleague, a respirologist now retired, who asked his patients to listen as he dictated their consult notes so that he could correct them immediately.
How lovely to hear. Partners in accuracy.
Absolutely right to correct it Maureen, because if the dying patient or the spouse had to, the pages of paperwork and procedures are a serious barrier to accuracy.
Medication lists /dosages, lab mix-ups, mistakes, checkmarks in boxes reversed, staff forgetting to convert inches to cm or pounds to kg and putting the wrong number in the fields (making me suddenly 7 inches taller, then 7 inches shorter on the next appt) have all happened to me, and it’s been a fight to change it everytime.
Worst one? Someone else’s psych record intake eval being filed in my record because the patient numbers were similar. Meanwhile, the other woman is 15 years younger, has no kids etc….pretty obvious it’s not me.
But I feel like, eh, eff it submitting paperwork and personally delivering it to the hospital. (Which is required) I can’t even submit the request to have fix the mistake through their secure EMR portal.
(And it’s not only cut and paste, it’s EMR design as well, when mistakes happen just because it’s hard to find the right spot, or slip and check the wrong box–EMR design is a big issue here.)