Your article “EHRs: Don't forget to edit “ (ACP Hospitalist, April 2013) nicely described some of the newer problems that have surfaced with the increasing use of electronic health records (EHRs). While the author did a good job of reviewing the clinical and practical issues that may result from excessive use of the “copy-and-paste” and “copy-forward” functions and the importance of reviewing notes to make sure the final product is accurate, I believe she omitted two important points.
First, progress notes that contain sections copied from prior days may negatively impact hospital reimbursement. Many hospitals are required to submit clinical reviews to insurance companies on a daily basis via their case management or utilization review department. In doing so, case managers rely on the progress notes to “tell the story” of why the patient remains in the hospital. A note with information copied from a prior day may present a significant challenge for the case manager. For example, at my hospital, ventilator settings were listed for a patient who had been extubated three days before the date of the progress note.
Daily progress notes can be invaluable in demonstrating the medical necessity of ongoing care for a hospitalized patient. If elements of the progress notes are copied from day to day, this makes the determination of ongoing medical necessity very challenging—and possibly delays payment for otherwise medically necessary care.
Second, progress notes with copied elements may pose a medicolegal risk. Since malpractice cases often occur far after the fact, the medical record is sometimes all that is concrete about a particular patient's care. In cases where documentation is copied and, more importantly, not edited, this may raise the level of risk by not accurately documenting the events that occurred in the care of the patient on whose behalf the malpractice case may be filed.
It is clear that physicians all need to do a better job of documenting accurately and clearly. When EHRs became more popular, it was thought that these issues would “go away.” However, what seems to have occurred is that EHRs have only created a new set of problems to overcome. The author did a great job of introducing the problems that may exist with inappropriate use of EHRs, but deeper issues may surface as time passes.
Frank L. Urbano, MD, FACP