Cutting and pasting in the age of online health records


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6 comments

  1. Aurelia

    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.)

  2. Barry Goldlist

    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.

  3. Dr Simon Moore www.drmoore.ca

    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.

  4. Michele

    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.

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