It is all too common for a section in a progress note to look something like this:
# Aspiration pneumonia:
- Continue vancomycin 1 g bid
- Continue Zosyn 3.325 g q6h
- Follow-up blood cultures
- Follow-up sputum cultures
- MRSA nares screen negative
- Blood cultures negative
- Discontinue vancomycin
Yesterday, a version of this note (lines 1 to 5 to be precise) had my name on it. Today, it is signed by someone else. Read it again if you did not see the problem.
While it is frustrating to see someone else taking credit for my work, it is most concerning that the author has not bothered to read his own official plan for the patient — a critically ill person whose life is entrusted to him that day. Many would argue that these minutiae do not matter and taking care of the patient is more important than having beautiful documentation. I agree. The problem is that with five or ten other patients on our service, the time we spend writing our notes is when we think about each patient most carefully. If we only take ten minutes to make cursory updates to yesterday’s progress notes, our care is also cursory. Our patients would be horrified if they knew this reality.
This haphazard copy-pasting has real consequences. When we fail to review our plan line-by-line, we are unlikely to carefully check all the medications the patient will receive that day. Updated physical exams are lost, and new bibasilar crackles or a subtle change in mental status might be missed. Trends in lab values are ignored: an AKI is documented as resolved even though the creatinine had been trending upwards for several days, and an unexpected transaminitis goes unnoticed. Plans regarding fluids, pain control, bowel regimens and even blood transfusions are glossed over. The effects can be fatal.
Ever since comprehensive electronic medical records (EMRs) proliferated, concerned physician-citizens have warned us of these consequences. Drs. Pamela Hartzband and Jerome Groopman, in an op-ed published ten years ago in the New England Journal of Medicine, wrote “Many times, physicians have clearly cut and pasted large blocks of text, or even complete notes, from other physicians; we have seen portions of our own notes inserted verbatim into another doctor’s note. This is, in essence, a form of clinical plagiarism with potentially deleterious consequences for the patient.”
To their credit, hospitals and EMR developers have tried to stem the tide of careless copy-pasting. At the bottom of each progress note in our hospital’s system, we are asked to attest that we have “reviewed, updated and verified this note’s content.” The Epic system now has a tool that highlights all copied text, though it also has tools to streamline copy-pasting.
These electronic reminders are a start, but the real solution is a change in culture. Putting one’s name on someone else’s note without attribution should not be any more acceptable in clinical practice than it is in a journal article or a high school English essay. When reusing their own notes, residents and attendings should be reminded to read them daily in their entirety. If it means arriving a half hour earlier in the morning or starting rounds a little later, then that is what we need to do to take care of our patients. Anything less is a real threat to patient safety.
Eric R. Gottlieb is an internal medicine resident.
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