Copy/Paste documentation of lifestyle counseling and glycemic control in patients with diabetes: true to form?

摘要

Electronic medical records (EMRs) can improve many aspects of patient care. Utilization of EMRs is increasing and is particularly encouraged by recent federal legislation. However, EMRs are not always used optimally. Concerns have been raised about inappropriate copying and pasting of information between health care provider notes. Up to 50% of the content of progress notes may be copied from older documents, and copying frequently leads to errors in documentation. However, whether copied text generally reflects the care delivered is not known.