In an effort to stimulate conversations about our campus environment, Scope presents another installment of Mindfulness in Medicine. This column, which first ran in September 2005 and returned in February 2011, aims to engage the IUSM community in discussion and reflection about our learning and working culture.
A Student Reports: On my last rotation in medical school I had an experience that all medical students should be aware of. I copied and pasted the past medical history of one of my patients from one of my resident’s previous note. In addition, I copied and pasted a long and complex problem list from another resident’s note for a patient that I had recently joined in on. At the time, I thought I was providing continuity of care and saving time. I saw nothing wrong in doing this because I had done it previously on many rotations and had seen many students, residents and attending physicians do the same. More to the point, I had actually been taught to do it by upper-level residents when I began my third-year clerkships.
When this was brought to my attention as a professionalism issue by the clerkship director, I was initially shocked. I felt unfairly singled out. Upon reflection, and after having done some research in this area, I realized that copying and pasting—while perhaps efficient in the short run—can have negative consequences that increase the risk of harm to patients. For example, if you’re in a hurry and copy and paste, it’s easy to forget to make the appropriate changes in a patient’s status or medications. This leaves the next person to care for the patient with an inaccurate chart. Also, it is important as medical students that we make our thought processes visible to those who evaluate us in order to demonstrate our clinical skills within and across cases.
Finally, in the age of social media and instant information, it is important to understand and uphold the principle of information integrity. Copying and pasting medical records is as much a breach of professionalism as copying and pasting from the Internet without citing sources. My main message is to always be mindful about your actions as you learn. Just because everyone else does it doesn’t make it right. As Ben Franklin reminds us, “An ounce of prevention is worth a pound of cure.” —Tory R. Caudle, MS IV
Commentary: The copy-and-paste function in electronic medical record (EMR) systems has enabled clinicians to improve their work efficiency. However, as this Mindfulness in Medicine incident reveals, it can also have far reaching consequences; avoiding negative impact on patient care is first foremost. Copied and pasted notes that are not changed to appropriately reflect the patient’s most up-to-date clinical status and/or care plans can certainly create confusion and potentially cause harm to that patient.
For example, a recent medical note describing a physical examination claimed the patient’s "abdomen was soft, non-tender and without masses." The problem with this note, which had obviously been copied and pasted, was that it described a woman who was 32 weeks pregnant! Once an error or inaccuracy is copied into subsequent notes from one day to the next—or even from one admission to the next—it can not only adversely impact patients but also other health care colleagues, including physician colleagues, nursing colleagues and other allied health care personnel, all of whom depend on having accurate notes on which to act.
The ethical and legal implications of copying notes must also be considered. Medical records are legal documents and, as such, are subject to laws covering fraud and misrepresentation. For clinical trainees (medical students and post-graduate trainees), the act of copying and pasting someone else’s work and making it your own without appropriate attribution is called plagiarism—a serious breach of ethics and professionalism that can be grounds for dismissal from a medical school or training program. For practicing clinicians, this issue can lead to legal consequences—through either lawsuits if patients were harmed or through governmental audits of charts, with the latter potentially leading to significant governmental fines for the entire health care institution.
The practice of copying and pasting can also adversely impact teaching and learning clinical medicine. Copied and pasted notes have a very low likelihood of accurately reflecting the latest changes in a patient’s clinical status and care plans. Yesterday’s number one problem may have improved or even resolved—although it remains the number one problem in today’s copied and pasted note—while new and very pressing issues are commonly tacked onto the end of the note. This type of documentation practice does not reflect the critical thinking and prioritizing skills needed of highly effective clinicians. Yet, because it is quicker and seen as a “time saver,” clinical trainees may quickly and easily adopt this practice (as role-modeled by their seniors) into their own repertoire.
As clinical teachers, faculty and residents need to role model proper clinical documentation practices for the most impressionable learners—medical students—so good habits of critical thinking and prioritizing are taught and learned early. In addition, as illustrated by this incident, it is crucial medical students document their own work in order to demonstrate their growing clinical skills to their teachers. Even a student who copies and pastes their own notes—and therefore does not make all the appropriate changes to reflect developments in their clinical thought process—will create a detriment to their clinical performance and growth as a clinician.
Finally, as we consider the social contract we have with the public, the issue of copying and pasting stands out as one that could further erode the public’s trust in the medical profession and lead to more regulation by external authorities. Copying and pasting is a very pervasive problem and everyone, regardless of their place in the system, can be part of the solution. And remember, “Just because everyone else does it doesn’t make it right.” —T. Robert Vu, MD, associate professor of medicine and medicine clerkship director, IUSM
Mindfulness in Medicine is an editorial collaboration among the Teacher-Learner Advocacy Committee, the Relationship-Centered Care Initiative and the Office for Medical Education and Curricular Affairs. Each column features true stories, letters, poetry or art from members of the IUSM campus community.
For more information on Mindfulness in Medicine, visit medicine.iu.edu/meca/publications/mindfulness-in-medicine-mandm.
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