6 Reasons Why Women Should Weight Train
Stay up to date on the latest trends in Exercise and Fitness. We think of muscles, we think of Popeye, not twiggy Olive Oil. But building and maintaining ...
Stay up to date on the latest trends in Exercise and Fitness. A habit like adding in a new exercise routine can be difficult—and stress...
Stay up to date on the latest trends in Exercise and Fitness. Grains of sand… infinite ways to get stressed over your health.
Stay up to date on the latest trends in Exercise and Fitness. Like exercise, they often talk about.
Stay up to date on the latest trends in Exercise and Fitness. As you start your journey to establish an aerobic exercise routine, keep in mind.
I strongly identify with the subject of the editorial by and Adelman.1 Many of the problems described regarding the “copy and paste” issue are of the same magnitude at our Medical Center.
As the director of one of the departments of internal medicine at our hospital, I have the opportunity to frequently review patients' charts and encounter the problems with copy and paste. Medical diagnosis in previous admissions that have no relevance for the present hospitalization are repeated and copied from one summary to the other. Previous medications are copied and printed as if they were the patient's even if the patient is no longer taking them. Data presented in a previous hospitalization are repeated without changing the or the date reader may not be able to understand or may misinterpret the data. Much information from past reports, for example, in admitted patients with coronary heart disease, is copied from previous charts and presented in the history of the present illness as a never-ending paragraph that is repeated to exhaustion with each hospitalization, whereas the actual and relevant history of the present illness is briefly presented in one small single line.
Copy and Paste of Electronic Health Records: A Modern Medical Illness
MD DOI:https://doi.org/10.1016/j.amjmed.2009.10.012
To the Editor:
I strongly identify with the subject of the editorial by and Adelman.1 Many of the problems described regarding the “copy and paste” issue are of the same magnitude at our Medical Center.
As the director of one of the departments of internal medicine at our hospital, I have the opportunity to frequently review patients' charts and encounter the problems with copy and paste. Medical diagnosis in previous admissions that have no relevance for the present hospitalization are repeated and copied from one summary to the other. Previous medications are copied and printed as if they were the patient's even if the patient is no longer taking them. Data presented in a previous hospitalization are repeated without changing the details or actualizing the date; the reader may not be able to understand or may misinterpret the data. Much information from past reports, for example, in admitted patients with coronary heart disease, is copied from previous charts and presented in the history of the present illness as a never-ending paragraph that is repeated to exhaustion with each hospitalization, whereas the actual and relevant history of the present illness is briefly presented in one small single line.
On some occasions, the same information is repeated over and over. In one of the charts I reviewed, the patient was referred, at his discharge, to a consultation to one of our colleges at our Medical Center. Because this information was not in accordance with the data presented in the chart, I looked for and realized that the same sentence appeared in a previous discharge. By reviewing older hospitalizations, I saw that the same reference to the with the same details was repeated again and again in previous hospitalizations and in several departments of our hospital by different physicians for about 7 years.
On another occasion, the summary recommendations for a deceased patient were as follows: a low sugar diet, follow-up by the family medicine and forthcoming consultation visit at our clinic whenever needed.
Efforts to solve this problem and keep the essential spirit of the clinical work, as stated in your editorial, are to be commended and hopefully will lead to a more reasonable and judicious use of these electronic records.
You must be logged in to post a comment.