The Effect of Documentation on Defensibility & Patient Safety
In medical malpractice claims, having a documentation failure as a contributing factor moves the defendant’s chance of winning a case from likely to unlikely.
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Case Study
Tripped Up by Copying and Pasting in the EHR
Description
An elderly patient with a known history of mobility limitations fell and broke their hip after leaving the podiatrists office with a newly applied walking boot.
Key Lessons
- Copying and pasting of past assessments in the medical record may perpetuate erroneous or outdated information being carried forward. Be cognizant of what is new and what is no longer relevant.
- Repeatedly copied clinical notes may give the impression that you do not care about the patient.
- Where such features are available, work with your organization to develop processes to distinguish new chart content and make relevant patient information easily accessible.
Clinical Sequence
An 85-year-old with a history of diabetic peripheral neuropathy with gait instability had been instructed many times to use an assistive device when ambulating. The patient consistently declined this advice and other treatments intended to reduce their risk of falling.
The patient presented to their primary care physician with a toe blister and was referred to podiatry on the same day. The Podiatrist debrided the wound, and placed the patient in a walking boot to relieve pressure on the their toe. The patient was not provided with instructions on the walking boot nor was their mobility with the boot assessed. When leaving the office, the patient fell and sustained a hip fracture.
Review of the medical record identified that portions of the podiatrist’s note were identical to notes from five years earlier stating that the patient walked “regularly.” This narrative, which was copied and pasted by the podiatrist, may have led to incorrect or leading information about the patient’s mobility.
Allegation
The patient alleged they were negligently prescribed a walking boot and were not instructed on how to use it.
Disposition
The case was settled.
Analysis
Clinical Issues
The physician copied and pasted an older note into the patient encounter. By relying on older information, the physician missed more up-to-date information that may have changed the treatment plan.
Rote copying of old notes into a new patient encounter opens the door to outdated information being perceived as current. As a result, future care providers may misunderstand which information is most relevant to the patient and the current care plan. Be cognizant of what is new versus outdated in the medical record. Review of the problem list and recent encounters may provide more relevant patient risk factors to inform the treatment plan.
Patient Perspective
The patient had a history of an unsteady gait increasing their fall risk. This was not noted by the physician nor the office staff before placing the patient in a walking boot.
Review in greater detail records that may reveal information about pertinent medical history and risk factors. The lack of additional education on the safe use of the walking boot and an evaluation of the patient’s gait to assess fall risk was a missed opportunity.
Legal Defense Perspective
The plaintiff’s counsel might be critical of the assessment and medical decision-making processes when they notice notes that are identical to past notes in the medical record.
When a note is copied and pasted, it can give the impression that you don’t care about the patient or were unobservant. It may become something that you need to explain and defend if named in a medical malpractice case.
References and Hyperlinks
- Tsou AY, Lehmann CU, Michel J, et al. “Safe Practices for Copy and Paste in the EHR: Systematic Review, Recommendations, and Novel Model for Health IT Collaboration.” Applied Clinical Informatics, 2017;8:12-34. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5373750/
- American Health Information Management Association: “Appropriate Use of the Copy and Paste Functionality in Electronic Health Records.” AHIMA Position Statement (accessed February 10, 2015)
- Partnership for Health IT Patient Safety Health IT Safe Practices: Toolkit for the Safe Use of Copy and Paste. February 2016. Includes implementation aids for organizations, including a training checklist, educational presentations, risk identification assessments (tailored for various stakeholders), self-assessment checklists, templates for policies and procedures, implementation plans and strategies for stakeholder groups, and audit and assessment tools which can be used to assess successful implementation.
- https://www.rmf.harvard.edu/Clinician-Resources/Newsletter-and-Publication/2013/Insight-Write-it-Right
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