International journal of medical informatics · 2022
An evaluation of copy and paste events in electronic notes of patients with hospital acquired conditions.
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Wang Ruixuan, Carrington Jane M, Hammarlund Noah, Sanchez Orlando, Revere Lee
Аннотация
BACKGROUND: The increased use of the copy and paste function (CPF) in Electronic Health Records (EHRs) has raised concerns about possible clinician miscommunication and adverse patient outcomes.
OBJECTIVE: This study investigated the prevalence and extent of CPF in the EHRs of patients diagnosed with Hospital-acquired Conditions (HACs). We also examined the association between the use of CPF and patient characteristics.
MATERIALS AND METHODS: The prevalence and extent of CPF were investigated using electronic clinical notes of 50 patients hospitalized with HACs between 2017 and 2021 at a large academic medical center. Study patients were adults aged 21 and older with a length of stay greater than three days. ANOVA analysis was used to examine the differences in CPF use between patients with different characteristics.
RESULTS: A total of 7,844 clinical notes across seven note types are compared in the study. The mean patient age was 63.7, with an average length of stay of 15.6 days. 54% of Discharge Summaries, 53% of Consults, and 47% of history and physical (H&P) notes had duplications with the same type of notes. In the Discharge Summary, ED notes, and Plan of Care, duplications accounted for 40% or higher of the full text. H&P and Consults, H&P and Discharge Summary, and Discharge Summary and Consults were more likely to have duplications than between other types of notes. Duplications accounted for 15.5% of the information provided in H&P and Consults. The prevalence of CPF was higher in the Discharge Summary of patients who were younger, female, and had longer hospital stays.
CONCLUSION: Both prevalence and extent of duplication were high in the Discharge Summary, Consults, and H&P notes of patients with HACs. Future studies are needed to examine the intention and appropriateness of CPF use and its impact on patient outcomes.
OBJECTIVE: This study investigated the prevalence and extent of CPF in the EHRs of patients diagnosed with Hospital-acquired Conditions (HACs). We also examined the association between the use of CPF and patient characteristics.
MATERIALS AND METHODS: The prevalence and extent of CPF were investigated using electronic clinical notes of 50 patients hospitalized with HACs between 2017 and 2021 at a large academic medical center. Study patients were adults aged 21 and older with a length of stay greater than three days. ANOVA analysis was used to examine the differences in CPF use between patients with different characteristics.
RESULTS: A total of 7,844 clinical notes across seven note types are compared in the study. The mean patient age was 63.7, with an average length of stay of 15.6 days. 54% of Discharge Summaries, 53% of Consults, and 47% of history and physical (H&P) notes had duplications with the same type of notes. In the Discharge Summary, ED notes, and Plan of Care, duplications accounted for 40% or higher of the full text. H&P and Consults, H&P and Discharge Summary, and Discharge Summary and Consults were more likely to have duplications than between other types of notes. Duplications accounted for 15.5% of the information provided in H&P and Consults. The prevalence of CPF was higher in the Discharge Summary of patients who were younger, female, and had longer hospital stays.
CONCLUSION: Both prevalence and extent of duplication were high in the Discharge Summary, Consults, and H&P notes of patients with HACs. Future studies are needed to examine the intention and appropriateness of CPF use and its impact on patient outcomes.