Journal Article

Prevalence of copied information by attendings and residents in critical care progress notes.

Thornton D, Schold JD, Venkateshaiah L, et al. Critical care medicine. 2013;41:382-8.

One unintended consequence of integrating information technology into health care has been the copy-and-paste phenomenon in clinical documentation—the verbatim copying of information from note to note, which can result in perpetuating incorrect or irrelevant information. This cohort study conducted in an academic medical center ICU found copying and pasting to be near universal among residents and attending physicians, with more than 20% of the note being directly copied from the prior day's note in nearly three-quarters of the notes analyzed. Prior studies have shown that physicians do not feel copying information impairs the quality of care. Although this study did not directly assess if errors occurred due to copying and pasting, an AHRQ WebM&M commentary illustrates how indiscriminate copying of information can lead to preventable harm.