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To the Editor: In A Piece of My Mind, Dr Hirschtick brings attention to the serious issue of clinical documentation quality in the electronic medical record (EMR) era.¹ His observations about the effects of computerized physician documentation are insightful and capture some of the frustration that physicians are experiencing. However, the issues raised are actually more complex than his essay might suggest.

Copying and pasting of clinical content undoubtedly occurs more frequently than is desirable, but the degree and nature of this activity can vary. From 9% to 20% of clinical notes may contain evidence of copying.^2-3 While most of this copying was simply the work of busy clinicians striving to be productive,³ some copying reflected author carelessness, laziness, and occasionally high-risk mistakes that could have contributed to medical errors. Moreover, physicians perceived that inappropriate copying was facilitated by EMRs, seemed more prevalent since the transition to computerized physician documentation, . . . [Full Text of this Article]

Thomas R. Yackel, MD, MPH, MS
yackelt@ohsu.edu
Oregon Health & Science University
Portland

Peter J. Embi, MD, MS
University of Cincinnati College of Medicine
Cincinnati, Ohio

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