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Before electronic health records: If you did not document it, you did not do it.
After electronic health records: You documented it, but did you do it?
After a slow start, hospitals in the United States have rapidly adopted electronic health records, as encouraged by the Health Information Technology for Economic and Clinical Health Act of 2009 (HITECH).1 By May 2013, more than 3800 hospitals, or about 80% of the hospitals that were eligible, had received incentive payments from the Centers for Medicare & Medicaid Services (CMS) related to the adoption, implementation, upgrading, or “meaningful use” of these records.2 Yet the application of electronic health records can be a double-edged sword. Their use can increase efficiency, facilitate information sharing, standardize hospital processes, and improve patient care1,3,4 But their use can also have unintended consequences and be subject to abuse, such as when data are duplicated or templates and checkboxes are used to generate standardized text without a good medical reason.
Sheehy AM, Weissburg DJ, Dean SM. The Role of Copy-and-Paste in the Hospital Electronic Health Record. JAMA Intern Med. 2014;174(8):1217-1218. doi:10.1001/jamainternmed.2014.2110