Cutting and pasting in the age of online health records
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.
Maureen Taylor is a physician assistant in infectious diseases at Michael Garron Hospital in Toronto.