Copy & Paste

Patients in the hospital get seen by a lot of people.  There's the admitting resident, the hospitalist, any number of consultants each with their own niche. And on transfer out of the ICU a new crew takes over.  As the consultant I do not ordinarily encounter the person on the first day.  By then they can give me a history, which I take, but I also read the History of Present Illness.  Too often, the HPI's done on Day 1 by different providers look a little too identical, though each signed independently.  If journalists did that it would be plagiarism though when doctors do it the term is copy & paste or even more benevolently, gathering needed information from available records.  That's an OK thing to do, even an expected thing to do.  Calling it your own is not, particularly if you never really gathered any information directly from the capable patient but misrepresented what you have done personally.

But while it enhances payment and reduces work, does it harm patient care?  To some extent I think it might, particularly when I look at my histories taken from the patient, usually in happier circumstances, have details and insights not elicited by others but could have been.  Histories are often tapestries, contributions from different interviewers who stumble across something unexpected by relevant that differs from information the previous person obtained.  And sometimes it makes all the difference