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The role of copying and pasting in electronic clinical documentation

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Title: The role of copying and pasting in electronic clinical documentation
Author: Jernigan, Michael, M.D. University of Tennessee
Other Contributors: Harvard University--MIT Division of Health Sciences and Technology.
Advisor: William Lester.
Department: Harvard University--MIT Division of Health Sciences and Technology.
Publisher: Massachusetts Institute of Technology
Issue Date: 2009
Abstract: 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.
Description: Thesis (S.M.)--Harvard-MIT Division of Health Sciences and Technology, 2009.Includes bibliographical references (leaves 21-22).
URI: http://hdl.handle.net/1721.1/47855
Keywords: Harvard University--MIT Division of Health Sciences and Technology.

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