The role of copying and pasting in electronic clinical documentation

Clinical documentation by physicians and nurses has struggled to evolve with advancing technology and societal requirements. Originally designed as a physician's personal notes for a patient, the modern medical record functions as a patient record, communication tool between providers, and instrument for financial reimbursement. Technology has played a pivotal part in advancing the role of the medical record. Advantages and disadvantages inherent in the introduction of each new technology have prompted much debate, but none more than the introduction of electronic documentation systems within electronic medical records. Electronic systems provide clear advantages of information exchange as well as decision and diagnostic support. They have also proven quite controversial, particularly in the initial implementation stages. One aspect of electronic documentation, electronic copying and pasting, provides a tool for the clinician that is not clearly beneficial or detrimental, with proponents on each side. In this paper we explore the social, economic, and legal issues surrounding electronic copying and pasting in clinical documentation, review the literature on this subject, and propose a model for future research in this topic to help shape how clinicians use and process patient information from multiple sources.

Department dc:contributor.department

Harvard University--MIT Division of Health Sciences and Technology.

Grantor dc:publisher

Massachusetts Institute of Technology

Year dc:date.issued

2009

Author dc:creator

• Jernigan, Michael, M.D. University of Tennessee

Advisor dc:contributor.advisor

• William Lester.

• Harvard University--MIT Division of Health Sciences and Technology.

Statement dc:rights

• M.I.T. theses are protected by copyright. They may be viewed from this source for any purpose, but reproduction or distribution in any format is prohibited without written permission. See provided URL for inquiries about permission.

Licence dc:rights.uri

• http://dspace.mit.edu/handle/1721.1/7582

Language dc:language.iso

eng

Handle dc:identifier.uri

http://hdl.handle.net/1721.1/47855

OAI identifier oai:identifier

oai:dspace.mit.edu:1721.1/47855