Ash JS, Berg M, Coiera E. Some unintended consequences of information technology in health care: The nature of patient care information system-related errors. JAMIA. 2004;11:104-112.
Hirschtick RE. A piece of my mind. Copy-and-paste. JAMA. 2006;295:2335-2336.
Thielke S, Hammond K, Helbig S. Copying and pasting of examinations within the electronic medical record. Int J Med Inform. 2007;76 Suppl 1:S122-128.
O'Donnell HC, Kaushal R, Barron Y, Callahan MA, Adelman RD, Siegler EL. Physicians' attitudes towards copy and pasting in electronic note writing. J Gen Intern Med. 2009;24:63-68.
Embi PJ, Yackel TR, Logan JR, Bowen JL, Cooney TG, Gorman PN. Impacts of computerized physician documentation in a teaching hospital: Perceptions of faculty and resident physicians. JAMIA;2004:300-309.
Hartzband P, Groopman J. Off the record -- avoiding the pitfalls of going electronic. N Engl J Med. 2008;358:1656-1658.
Siegler EL, Adelman R. Copy and paste: A remediable hazard of electronic health records. Am J Med. 2009;122:495-496.
AHIMA. Auditing copy and paste. J AHIMA. 2009;80:26-29.
Hammond KW, Helbig ST, Benson CC, Brathwaite-Sketoe BM. Are electronic medical records trustworthy? Observations on copying, pasting and duplication. AMIA Annu Symp Proc. 2003;2003:269-273.
Croskerry P. The importance of cognitive errors in diagnosis and strategies to minimize them. Acad Med. 2003;78:775-780.
Epstein RM, Hundert EM. Defining and assessing professional competence. JAMA. 2002;287:226-235.
Schiff GD, Bates DW. Can electronic clinical documentation help prevent diagnostic errors? N Engl J Med. 2010;362:1066-1069.
ABIM Foundation; ACP-ASIM Foundation; European Federation of Internal Medicine. Medical professionalism in the new millennium: a physician charter. Ann Intern Med. 2002;136:243-246.
Snyder L; American College of Physicians Ethics, Professionalism, and Human Rights Committee. American College of Physicians Ethics Manual: sixth edition. Ann Intern Med. 2012;156:73-104.
Verghese A, Brady E, Kapur, CC, Horwitz, RI. The bedside evaluation: Ritual and reason. Ann. Intern. Med. 2011;155:550-553.
Rosenthal GE, Wilson, MC. Ctrl C, Ctrl V: A new threat to medical practice and education. SGIM Forum. 2009;32:1.
Ericsson KA. Deliberate practice and the acquisition and maintenance of expert performance in medicine and related domains. Acad Med. 2004;79:S70-81.
Association of American Medical Colleges. Appropriatedocumentation in an EHR: Use of information that is not generated during the encounter for which the claim is submitted: Copying/Importing/Scripts/Templates. 2011. https://www.aamc.org/download/253812/data/appropriatedocumentationinanehr.pdf Accessed November 14, 2011.
American Health Information Management Association. Copy Functionality Toolkit. 2008. http://campus.ahima.org/audio/2009/RB111709.pdf Accessed November 21, 2011.
University of Illinois at Chicago. Copy and paste function in the electronic medical record. April 2006.
http://chicago.medicine.uic.edu/UserFiles/Servers/Server_442934/File/Compliance/G-
4.4%20Copy%20and%20Paste%20Function%20in%20the%20Electronic%
20Medical%20Record.pdf Accessed November 14, 2011.
Department of Veterans Affairs South Texas Veterans Health Care System. Policy Memorandum 11 – . Copy and Paste (Cloned Notes). http://www.uthscsa.edu/gme/documents/va-copypaste.pdf Accessed November 29, 2011.

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Authors

Susan Rattner, MD

Associate Dean for Undergraduate Medical Education, Jefferson Medical College, Philadelphia, Pennsylvania

Disclosures

Disclosure: Susan Rattner, MD, has disclosed no relevant financial relationships.

Michele Mathes, JD

Senior Associate, Center for Ethics and Professionalism, American College of Physicians, Philadelphia, Pennsylvania

Disclosures

Disclosure: Michele Mathes, JD, has disclosed no relevant financial relationships.

Eugenia Siegler, MD

Weill Medical College of Cornell University; New York Presbyterian Hospital, Department of Medicine, Division of Geriatrics and Gerontology, New York, New York

Disclosures

Disclosure: Eugenia Siegler, MD, has disclosed no relevant financial relationships.

Editor

Lois Snyder, JD

Director, Center for Ethics and Professionalism, American College of Physicians, Philadelphia, Pennsylvania

Disclosures

Disclosure: Lois Snyder, JD, has disclosed no relevant financial relationships.

CME Author

Laurie Barclay, MD

Freelance writer and reviewer, Medscape, LLC

Disclosures

Disclosure: Laurie Barclay, MD, has disclosed no relevant financial relationships.

CME Reviewer(s)

Nafeez Zawahir, MD

CME Clinical Director, Medscape, LLC

Disclosures

Disclosure: Nafeez Zawahir, MD, has disclosed no relevant financial relationships.

Sarah Fleischman

CME Program Manager, Medscape, LLC

Disclosures

Disclosure: Sarah Fleischman has disclosed no relevant financial relationships.

CME

Copied and Pasted and Misdiagnosed (or Cloned Notes and Blind Alleys)

Authors: Susan Rattner, MD; Michele Mathes, JD; Eugenia Siegler, MD
CME Released: 5/16/2012; Reviewed and Renewed: 6/5/2015
THIS ACTIVITY HAS EXPIRED FOR CREDIT
Valid for credit through: 6/5/2017

Start Activity

Target Audience and Goal Statement

This activity is intended for internists, intensivists, hospital practitioners, and other clinicians caring for patients in whom EHRs are used.

The goal of this activity is to describe potential problems associated with use of EHRs and strategies to overcome these problems.

Upon completion of this activity, participants will be able to:

Describe potential EHR problems associated with note copying
Describe other potential problems associated with medical record documentation
Describe possible strategies to overcome potential problems associated with use of EHRs

Disclosures

Authors

Susan Rattner, MD

Associate Dean for Undergraduate Medical Education, Jefferson Medical College, Philadelphia, Pennsylvania

Disclosures

Disclosure: Susan Rattner, MD, has disclosed no relevant financial relationships.

Michele Mathes, JD

Senior Associate, Center for Ethics and Professionalism, American College of Physicians, Philadelphia, Pennsylvania

Disclosures

Disclosure: Michele Mathes, JD, has disclosed no relevant financial relationships.

Eugenia Siegler, MD

Weill Medical College of Cornell University; New York Presbyterian Hospital, Department of Medicine, Division of Geriatrics and Gerontology, New York, New York

Disclosures

Disclosure: Eugenia Siegler, MD, has disclosed no relevant financial relationships.

Editor

Lois Snyder, JD

Director, Center for Ethics and Professionalism, American College of Physicians, Philadelphia, Pennsylvania

Disclosures

Disclosure: Lois Snyder, JD, has disclosed no relevant financial relationships.

CME Author

Laurie Barclay, MD

Freelance writer and reviewer, Medscape, LLC

Disclosures

Disclosure: Laurie Barclay, MD, has disclosed no relevant financial relationships.

CME Reviewer(s)

Nafeez Zawahir, MD

CME Clinical Director, Medscape, LLC

Disclosures

Disclosure: Nafeez Zawahir, MD, has disclosed no relevant financial relationships.

Sarah Fleischman

CME Program Manager, Medscape, LLC

Disclosures

Disclosure: Sarah Fleischman has disclosed no relevant financial relationships.

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From American College of Physicians Ethics Case Studies

CME

Copied and Pasted and Misdiagnosed (or Cloned Notes and Blind Alleys)

Authors: Susan Rattner, MD; Michele Mathes, JD; Eugenia Siegler, MDFaculty and Disclosures

THIS ACTIVITY HAS EXPIRED FOR CREDIT

CME Released: 5/16/2012; Reviewed and Renewed: 6/5/2015

Valid for credit through: 6/5/2017

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Introduction

This case study is one in a series with commentaries by the American College of Physicians’ (ACP) Ethics, Professionalism and Human Rights Committee and the Center for Ethics and Professionalism. The series uses hypothetical examples to elaborate on controversial or subtle aspects of issues not addressed in detail in the College's Ethics Manual, the Physician's Charter on professionalism, or other College position statements. The sixth edition of the ACP's Ethics Manual, the Physician's Charter, and additional College policies on ethics, professionalism, and human rights issues are available at http://www.acponline.org/ethics/ethics_man.htm or by contacting the Center for Ethics and Professionalism at
215/351-2839.

Page 1 of 4

Case

CME Information

Introduction
Case
Commentary
Conclusion

References

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Disclaimer

The educational activity presented above may involve simulated case-based scenarios. The patients depicted in these scenarios are fictitious and no association with any actual patient is intended or should be inferred.

The material presented here does not necessarily reflect the views of Medscape, LLC, or companies that support educational programming on medscape.org. These materials may discuss therapeutic products that have not been approved by the US Food and Drug Administration and off-label uses of approved products. A qualified healthcare professional should be consulted before using any therapeutic product discussed. Readers should verify all information and data before treating patients or employing any therapies described in this educational activity.

References

Faculty and Disclosures

Authors

Susan Rattner, MD

Michele Mathes, JD

Eugenia Siegler, MD

Editor

Lois Snyder, JD

CME Author

Laurie Barclay, MD

CME Reviewer(s)

Nafeez Zawahir, MD

Sarah Fleischman

CME

Copied and Pasted and Misdiagnosed (or Cloned Notes and Blind Alleys)

Target Audience and Goal Statement

Disclosures

Authors

Susan Rattner, MD

Michele Mathes, JD

Eugenia Siegler, MD

Editor

Lois Snyder, JD

CME Author

Laurie Barclay, MD

CME Reviewer(s)

Nafeez Zawahir, MD

Sarah Fleischman

Accreditation Statements

For Physicians

Instructions for Participation and Credit

Copied and Pasted and Misdiagnosed (or Cloned Notes and Blind Alleys)

Introduction

Table of Contents