Copy/Paste Documentation of Lifestyle Counseling and Glycemic Control in Patients With Diabetes: True to Form?

Abstract

Electronic medical records (EMRs) can improve many aspects of patient care(1). Utilization of electronic medical records is increasing and is particularly encouraged by recent federal legislation(2). However EMRs are not always used optimally. Concerns have been raised about inappropriate copying and pasting of information between provider notes(3, 4). Up to 50% of the content of progress notes may be copied from older documents(5, 6) and copying frequently leads to errors in documentation(6). However, whether copied text generally reflects the care delivered is not known. Lifestyle counseling improves outcomes in patients with diabetes and is recommended by treatment guidelines(7). Narrative provider notes are the primary source of information on whether lifestyle counseling was provided. However, if copying and pasting of note fragments does not reflect treatment, the information contained in narrative electronic documents may not be reliable. We therefore performed a retrospective study of over 5,000 patients with diabetes to determine the relationship between copied lifestyle counseling and glucose control.