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Research Letter
Aug 8 2011

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

Author Affiliations

Author Affiliations: Divisions of Endocrinology (Drs Turchin and Shubina) and General Medicine (Dr Einbinder), Brigham and Women's Hospital, Boston, Massachusetts; Harvard Medical School and Clinical Informatics Research and Development, Partners HealthCare System, Boston (Drs Turchin, Breydo, and Einbinder); and Department of Radiation Oncology, Massachusetts General Hospital, Boston (Dr Goldberg).

Arch Intern Med. 2011;171(15):1393-1400. doi:10.1001/archinternmed.2011.219

Electronic medical records (EMRs) can improve many aspects of patient care.1 Utilization of EMRs 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 health care 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 notes by health care providers 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.