Dangerous and Deadly
The copy-and-paste function of the Electronic Health Record is a dangerous feature. I have personally reviewed medical cases where a patient was noted to have diabetes, but didn’t. It was an error by the initial author of the Past Medical History, but copied and pasted to each physician’s assessment. A pressure ulcer was assessed as a stage II (wrong assessment) and copied and pasted in the nursing notes for weeks. The physicians reading the nursing notes were unaware that the pressure was actually a large unstageable pressure ulcer. The patient did not receive the proper treatment and died from sepsis.
Each and every author is responsible for their documentation. If they electronically sign an assessment they are stating that the documentation is true and correct.
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