Medicine is rapidly changing with the advances in technology. Few will argue the benefits of having an EMR are great. However, there are also a number of increased risks. One major risk, happening at an alarming rate is “note bloat” caused by improper copy – paste within the clinical notes.
In a recent study performed by researchers at the University of California San Francisco, it was determined that a mere 18% of inpatient notes in EPIC were manually entered at UCSF Medical Center. This means that 80% of notes were copied or imported from somewhere else.
Copy – paste functionality is acceptable, but the provider MUST properly edit. There must be clear evidence as to what happened during the clinical encounter. It is essential the integrity of clinical documentation is held to the highest standards for both the safety of the patient and the institution.
JAMA Internal Medicine – published May 30, 2017