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This WebM&M describes two cases illustrating several types of Electronic Health Record (EHR) errors, with a common thread of erroneous use of electronic text-generation functionality, such as copy/paste, copy forward, and automatically pulling information from other electronic sources to populate clinical notes. The commentary discusses other EHR-based documentation tools (such as dot phrases), the influence of new documentation guidelines, and the role of artificial intelligence (AI) tools to capture documentation.
A 32-year-old man presented to the hospital with a comminuted midshaft femoral fracture after a bicycle accident. Imaging suggested the fracture was pathologic and an open biopsy specimen was submitted to pathology for intraoperative consultation.
Concern over patient safety issues associated with inadequate tracking of test results has grown over the last decade, as it can lead to delays in the recognition of abnormal test results and the absence of a tracking system to ensure short-term patient follow-up.1,2 Missed abnormal tests and the lack of necessary clinical follow-up can lead to a late diagnosis.
Allen A. KFF Health News. June 21, 2023.
Gammon K. STAT. June 26, 2023.
Washington DC: Department of Veterans Affairs, Office of Inspector General; May 10, 2023. Report no. 22-01116-110.
May 31, 2023; Fed Register;88:35694-35728.
Levi R, Gorenstein D. Health Shots. National Public Radio. June 6, 2023.