A 78-year-old man with hypertension and diabetes presented to an emergency department (ED) with new onset chest pain. The ED physician reviewed the patient's electronic medical record (EMR) and noted a history of "PE" listed under the Past Medical History section. This raised his suspicion for the possibility of a pulmonary embolus (PE). After initial testing excluded a cardiac etiology, a computed tomography (CT) scan of the chest was ordered to rule out a PE. When the physician approached the patient to explain why he was ordering the diagnostic test, the patient denied ever having a PE or being treated with blood thinners.
Puzzled by the conflicting reports, the ED physician returned to the EMR and noted that this mistaken history of PE dated back several years. It even appeared in the "problem list" section of his EMR. Investigating further back, the ED physician discovered that the letters "PE" were first noted nearly a decade earlier where it was clearly intended to reflect a "physical examination" rather than a "pulmonary embolus." A physician likely copied and mistakenly pasted "PE" under "past medical history," after which this history of pulmonary embolism was carried forward time and time again. The patient, who was ultimately discharged from the ED, never suffered any harm from the documentation error. The EMR was updated to reflect, "This patient never had a pulmonary embolism."
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