Peer Reviewed Articles About Copy and Paste in the Ehr

1 Introduction

Medical records refer to patient records that capture diverse conditions, examinations, differential diagnoses and handling plans performed past medical providers engaged in medical services. Electronic health records (EHRs) are stored on a computer, and computer operating systems provide many convenient functions, such as copying and pasting, which tin salve time. EHRs are different from other electronic files because they tape the patient's condition and adjustments to handling.

The widespread adoption of EHRs has led to pregnant progress in the modernization of healthcare delivery. According to health provider surveys, EHR adoption tin improve healthcare compared with paper-based medical records.^[one] Physicians use EHRs to completely, succinctly, accurately and quickly certificate a patient's condition for their ain use and their colleagues' use. The benefits of EHRs include improved admission to records, the facilitation of communication, increased quality of patient-centered intendance through clinical decision support and prophylactic engineering science, toll savings, and improved data direction for medical research and education.^[2,3] In a previous report, we found that the adoption level of EHRs may be related to healthcare quality, with improved quality in the full-EHR stage compared with the no-EHR phase.^[iv]

Medical documentation has evolved with the rapid growth in the use of EHRs. Physicians spend 26% of their time on clinical documentation and xviii% of their time writing on computers.^[five] The terms "cut" and "paste" were originally coined in reference to the concrete process of cut and pasting paragraphs betwixt different locations during the process of manuscript editing. About all EHR software allows for information to be moved from near whatsoever part of a patient'due south record to some other section. The results of by study indicate that the bulk of physicians work on EHRs, and the review demonstrated that 7.4% of alphabetize notes related to diagnostic errors were copied and pasted from prior visit notes. In these cases, the authors concluded that mistakes in copying and pasting contributed to 35.7% of errors.^[6] The diagnosis mistake rate due to the use of the copy-and-paste office is approximately ii.6%,^[7] but a significant bear on on patient safety issues was not constitute.^[6,eight] Using copying and pasting can salvage time, allowing physicians to focus on addressing the current illness and making adjustments. In the fast-paced medical globe, EHRs sanction copying and pasting with word templates and embedded problem lists. The word template of new medical notes was compared with previous notes past the text bank check method with a threshold of similarity to the restricted employ of copying and pasting. Even so, copying and pasting can crusade data integrity bug due to unnecessarily long entries, poor organization, less accurate run across tracking of medical atmospheric condition, inferred communication amongst users, diagnosis errors induced by false assumptions or attribution of authorship, and regulatory concerns about the accuracy and medical necessity of billed services.^[ix–14] The negative consequences for physicians are credible; thus, the effects of technological efficiency must be re-evaluated. This arroyo risks overlooking new or irresolute information and allows the perpetuation of prior inaccuracies.^[xiv] Junior physicians in training may not learn how to have an appropriately detailed history, behave a physical examination, collaborate with patients and family, or construct a broad differential thought procedure.^[11]

There are some controversial views about the use of the copy-and-paste function. This function was non institute to be associated with glucose command when information about lifestyle counseling was copied, and its apply led to poorer results in evaluations and direction.^[15,16] Orthopedic trauma was repeated in 85% of inpatient records^[17] and in 75% of outpatient ophthalmology records.^[eighteen] A previous study has shown that an intervention with notation-writing guidelines can better questions about the quality of EHRs just cannot influence the results of copying and pasting.^[13]

Internal institutional policies should exist created along with best practices to restrict the use of the re-create-and-paste function. The electric current technology could be harnessed to improve provider productivity and could effectively be integrated into comprehensive patient care. A thoughtful and measured approach is favored, which would need to include staff pedagogy and the conscientious monitoring of notes. Bloated notes containing inaccuracies and oversights are regarded as unsafe, inefficient, and unprofessional. The inappropriate apply of copying and pasting should be viewed as a patient safety issue.^[nine] Longer notes could pb to reader fatigue. One study showed a negative human relationship between medical pupil performance and longer documentation.^[19]

Nosotros hypothesize that avant-garde restrictions on the use of the copy-and-paste function have the potential to affect inpatient healthcare quality and influence timely note completion. Physicians may overrely on the copy-and-paste function to meet timeline goals, and they must perform articulate history taking and concrete examinations with accurate adjustments and optimal treatments.

2 Materials and methods

This retrospective observational study used clinical documentation from an inpatient dataset of EHRs at the Tri-Service General Hospital from 2016 to 2018. The Tri-Service General Hospital is a medical eye that provides tertiary service in northern Taiwan. To prevent the overdocumentation of clinical notes, the hospital designed internal policies and identified the pct of copied-and-pasted text in clinical notes. Electronic tools detected word template similarities between clinical notes to identify those copied and pasted from previous visit notes. To reduce the overuse of copied and pasted text, the institution needed to develop a policy. The threshold for determining whether a progress annotation was copied and pasted was restricted to 70% similarity to previous documents using tongue programming and text mining^[twenty,21] starting in July 2016 at the Tri-Service General Hospital. If the similarity was more than seventy%, the computer would not save the progress notation, similar to a plagiarism detection checker. This report explored the correlation between the prevalence of copied-and-pasted text, healthcare quality and timely documentation completion status.

The 14-day readmission rate, length of stay and inpatient bloodshed rate were evaluated to measure healthcare quality. The 14-day readmission data were obtained from a discharge dataset of patients with the aforementioned diagnosis based on comparison the belch date of the focal admission with the side by side admission within a fourteen-24-hour interval period. The 14-mean solar day readmission rate was the number of readmission cases within xiv days divided by the discharge survival cases. The readmission rate was related to inpatient medical care, belch family care, and inpatient healthcare quality and was surveyed in past studies.^[22] The discharge summary notation is a summary of the patient's history, examinations, treatments and discharge programme, and its timely completion supports medical provider communication while patients visit the outpatient or unplanned emergency department and are readmitted. The policy-restricted use of copying and pasting reduced the completion rate of medical notes in past studies. The timely completion status of the documentation was assessed by identifying the rate of belch summary annotation completion within iii days. To understand the tendency of the prevalence of copying and pasting after the restricted use of copying and pasting was implemented, scenarios were based on breakpoints using segmented regression 11.96 months and xv months afterwards policy implementation (Supplementary Digital Content Figure, https://links.lww.com/MD2/A856 Segmented regression of the prevalence of copying and pasting after policy implementation). Iv stages were identified according to the time of the implementation of the copy and paste restriction policy and the breakpoints of the prevalence of copying and pasting after the brake implementation: the premonitoring stage (January 2016–June 2016); scenario 1, descending phase (July 2016–May 2017); scenario ii, ascending phase (June 2017–September 2017); and scenario three, fluctuation phase (September 2017–Dec 2018). The flowchart for this study is shown in Figure 1. The written report was approved past TSGH IRB 1-108-05-179 (ethical approving date: November 11, 2019).

Figure ane:

The flowchart of the protocol of this study.

The inclusion/exclusion criteria were as follows: ten percent of the inpatient notes were checked for the repeat rate every calendar month. The healthcare quality was surveyed every month.

The prevalence of copied-and-pasted text, the charge per unit of belch summary annotation completion within 3 days, and inpatient mortality (Shapiro–Wilk test: 0.403, 0.678, 0.083, 0.344) were fitted as normally distributed. The charge per unit of readmission within 14 days (Shapiro–Wilk < 0.001) was not fitted as normally distributed.

Continuous variables were assessed with Student t test with a significance threshold of P < .05. For the segmented analysis of the prevalence of copying and pasting later implementation of the restriction policy, the segmented packet in R was used.^[23] The rates of the belch summary note beingness completed within iii days in the different postal service-restriction scenarios were compared with those in the pre-restriction period. Nosotros performed a multifractal cantankerous-correlation analysis of the rate of readmission for the aforementioned disease within 14 days compared with the prevalence of copied-and-pasted text to calculate the lag time between the time series, and the highest correlation coefficient was selected. Poisson regression was performed to assess the relative issue of the re-create-and-paste restriction policy on the 14-twenty-four hours readmission rate with a 1-month lag or discharge annotation completion rate within 3 days. The analysis was performed with IBM SPSS Statistics for Windows, Version 22.0 (IBM Corp., Armonk, NY).

iii Results

There were a total of 142,039 patients with 167,736 medical records in this study. The boilerplate numbers of almanac discharges were approximately 25,561 and 14,967 for internal medicine and surgery, respectively, from 2016 to 2018. The almanac average discharge number was approximately 2168 in gynecology and obstetrics, approximately 1697 in pediatrics, approximately 1727 in otorhinolaryngology and approximately 1188 in ophthalmology. Nosotros compared the variables between the premonitoring and postmonitoring stages. The prevalence of copying and pasting was significantly reduced, from 35.72 ± 5.53% to 23.71 ± 6.9% (P = .001), after monitoring. The overall charge per unit of readmission for the aforementioned illness within 14 days was reduced from iii.46 ± 0.43% to 1.five ± i.03% (P < .001), reflecting reductions in internal medicine, surgery, gynecology and obstetrics, and otolaryngology. The charge per unit of discharge summary notation completion within 3 days decreased from 93.73 ± 1.39% to 91.77 ± 1.67% (P = .011) afterwards monitoring. However, the length of stay and inpatient bloodshed were non significantly dissimilar (Table 1).

Tabular array one - The characteristics of the pre-monitoring and post-monitoring periods for copying and pasting.

	Prerestriction (SD) 26326	Postrestriction (SD) 141410	P
Prevalence of copy and paste (%)	35.72 (five.53)	23.71 (vi.9)	.001∗
fourteen-24-hour interval readmission rate (%)	3.46 (0.43)	1.5 (1.03)	<.001∗
Internal medicine (%)	4.57 (0.48)	two.01 (one.15)	<.001∗
Surgery (%)	2.39 (0.5)	1.01 (0.88)	<.001∗
GYN and OBS (%)	3.94 (1.85)	1.09 (1.07)	.011∗
Pediatric (%)	0.53 (0.45)	0.24 (0.32)	.191
Otolaryngology (%)	one.68 (1.07)	0.43 (0.72)	.033∗
Inpatient mortality (%)	2.70 (0.43)	2.75 (0.31)	.764
Length of stay (days)	vi.six (seven.88)	6.68 (7.89)	.983
The rate of belch summary annotation completion inside 3 d (%)	93.73 (1.39)	91.77 (1.67)	.011∗
Example mix index	ane.two (0.02)	1.2 (0.03)	.833

GYN and OBS = gynecology and obstetrics, SD = standard deviation.

^∗ P < .05.

The scenarios were based on the breakpoints at eleven.96 months and 15 months after policy implementation. Postrestriction scenario i showed that the prevalence of copying and pasting decreased (gradient: −1.459%/month). Then, the prevalence of copying and pasting increased (slope: 2.807%/month) in postrestriction scenario 2, followed by fluctuations (gradient: −0.546%/calendar month) in postrestriction scenario 3. The decreasing trend with a relative hazard (RR) every calendar month was 0.979 (95% confidence interval [CI]: 0.963–0.996, P = .015) during the premonitoring phase with prepolicy education. The decreasing trend with RR was 0.977 (95% CI: 0.966–0.989, P = .002) during scenario ane after restriction. The increasing trend with RR was one.077 (95% CI: 0.997–1.163, P = .054) during scenario two later restriction. The decreasing trend with RR was 0.992 (95% CI: 0.972–1.012, P = .396) during scenario 3 after restriction.

The prevalence of copied-and-pasted text decreased compared with that in the prerestriction stage: 35.72 ± 5.53 vs 26.62 ± 5.78 (P = .009) during scenario 1 later restriction; 35.72 ± five.53 vs 22.83 ± v.57 (P = .01) during scenario ii after restriction; and 35.72 ± 5.53 vs 21.eight ± seven.57 (P < .001) during scenario 3 later on brake. The readmission rate for the same disease within 14 days decreased from 3.46 ± 0.43 to 2.68 ± 0.81 (P = .02) until 11 months of restriction (Fig. 2). The highest three-mean solar day note completion charge per unit was 95.8% in April 2016, and the lowest was 87.6% in May 2017 (Fig. 3). The decrease in the rate of 3-solar day belch summary annotation completion after monitoring continued until May 2017 (93.73 ± i.39% vs 90.59 ± 1.62%, P = .001) (Tabular array 2).

Figure 2:

The correlation between the prevalence of copying and pasting and the rate of readmission for the aforementioned disease inside fourteen days.

Figure iii:

The rate of discharge summary note completion inside 3 days.

Tabular array two - The divergence in the mail-restricted scenario compared with the prerestricted phase using bonferroni correction for multiple comparisons.

	Prevalence of copy and paste		14-solar day readmission charge per unit		3-day completion rate
Stage	Mean ± SD	P	Mean ± SD	P	Mean ± SD	P
Prerestricted	35.72 ± 5.53		3.46 ± 0.43		93.73 ± i.39
Postrestricted scenario i	26.62 ± 5.78	.009∗	ii.68 ± 0.81	.02∗	90.59 ± ane.62	.001∗
Postrestricted scenario 2	22.83 ± v.57	.01∗	0.86 ± 0.12	<.001∗	91.76 ± 1.48	.078
Postrestricted scenario three	21.8 ± 7.57	<.001∗	0.81 ± 0.fifteen	<.001∗	92.64 ± 1.25	.13

SD = standard difference.

^∗ P < .05.

The prevalence of copied-and-pasted text was related to the rate of readmission for the same disease inside fourteen days, with a 1-month lag (cantankerous-correlation coefficient = 0.616). The RR of ane.105 (95% CI: 1.064–ane.147, P < .001) of the fourteen-day readmission rate was affected by the prevalence of copying and pasting, with a 1-month lag. The RR of 1.043 (95% CI: 0.971–one.119, P = .248) of the discharge note completion charge per unit was affected past the prevalence of copying and pasting.

4 Give-and-take

According to this time-series study, the charge per unit of readmission for the same illness within xiv days is potentially moderately associated with the prevalence of copied-and-pasted text. The effects of the copying-and-pasting intervention on physicians' habits appeared to persist for approximately 1 year, with fluctuations. Adequate training and education are needed to reduce the increasing prevalence of copying and pasting. The rate of discharge summary note completion within 3 days was college before the copy-and-paste intervention. Subsequently restriction of the copy-and-paste procedure, the timely completion rate decreased for several months. This study can contribute to the understanding of changes in the prevalence of text copying and pasting in medical records, enhance patient care and reduce the learning period for timely annotation completion.

Compared with traditional paper-based medical records, EHRs improve legibility and accessibility while decreasing costs considering paper-based methods are cumbersome and fourth dimension consuming for physicians.

EHRs in prototype reports have been utilized at our hospital since 2009; belch summary notes were implemented in 2011; and inpatient nurse notes and outpatient medical records were implemented in 2013. Inpatient progress notes and notes from the emergency department were implemented in 2015, and inpatient medication notes have been utilized since 2017. Our previous study found that healthcare quality, including inpatient bloodshed and the length of stay showed no pregnant changes between partial (2015–2016) and full EHR (2017–2018) stages,^[4] merely healthcare quality must exist further improved with EHR adoption after 2015. Importing technology such as copying and pasting is mutual, useful and user-friendly for documentation and clinical notes, but its use in clinical documentation is controversial. The advantages of using the copy-and-paste office include the efficiency in data capture, improved timeliness, legibility, consistency, abyss, communication, and positive payment and outcome measures. However, excessive utilise can pb to the recording of inaccurate or outdated information about patients. This is an important result that requires improvement. Excessive use of copied and pasted text in EHRs can increase the efficiency of patient care but tin can besides touch patient safety and nowadays legal and ethical issues. It may also lead to the introduction of inaccurate data and oversights in the patient records, poor communication of the patient'southward current status, and subsequent diagnostic inaccuracies and a reduction in patient prophylactic.^[nine]

Physicians may overrely on the copy-and-paste function to meet timeline goals. Physicians spend 26% of their fourth dimension on clinical documentation and 18% of their time writing on computers. Copying and pasting can salve time, allowing physicians to focus on addressing the current disease and making adjustments.^[24] The prevalence of copied-and-pasted text was 25% in the documentation on discharge plans, goals of hospitalization and the estimated length of stay.^[25] A practical solution needs to be developed, and identifying the percentage of copied-and-pasted text in clinical notes may be a helpful adjunct in reviewing the documentation of care. It was worth surveying the influence of the policy of copying-and-pasting restriction on healthcare quality. We retrospectively analyzed the prevalence of copied-and-pasted text since 2016 and found that the outset of the third quarter of 2016 after the intervention had a particularly noticeable change: the prevalence persistently decreased to the lowest annual average of 21.82% in 2018. The trends showed a 2.ane% subtract per month in the premonitoring stage, a 1.459% decrease per month in scenario 1 after restriction, and a 0.546% decrease per month in scenario three afterwards restriction. In a previous written report that analyzed assessment and treatment plans in the intensive intendance unit of measurement during 2009, 20% of the text in 82% of notes from residents and 74% of notes from attending physicians was establish to include copied information.^[26] We plant that the prevalence of copied-and-pasted text was 40% before the brake and decreased to less than xx% each twelvemonth afterward the brake policy was implemented. A good text mining tool for identifying duplications and adequate policies could reduce the prevalence of duplications. There were 2 peaks: in 2018, during the Chinese New year, when fewer medical providers were present during the holiday in February, and at the fourth dimension when new interns and residents arrived to the hospital being not familiar with the process easy to duplication the notes in May.

The rate of readmission for the aforementioned affliction within 14 days showed a decreasing trend year past year. In this case, the RR, which is affected by copied-and-pasted text, was reduced to a level similar to that in past studies, showing its effectiveness for improving patient safety. Patient encounters deserve focus to establish adept patient–dr. relationships and in-depth knowledge of EHRs. The rates in pediatrics did non change later the intervention, potentially due to greater complexities in pediatric patient intendance and pediatricians investing more fourth dimension in caring for patients. A previous written report showed that EHRs are non related to quality in the pediatric section.^[27]

Because the policy induced reduced copying and pasting at kickoff, doctors adapted to the policy. The infirmary monitored the similarity rate and implemented promotional instruction to let the similarity charge per unit stabilize. With the establishment of the mechanism of prevention of copying and pasting in the third quarter of 2016, the institute controlled the prevalence of copied-and-pasted text using natural language programming and text mining. Because of the need to adapt at the initial stage of implementation, there was initially a reduction in the prevalence of copied-and-pasted text and a reject in the timely completion rate of medical records. The adaptation period later on 11 months showed a brief ascending trend, followed by stability. The timely note completion rate showed a decline following the restriction and then recovered in the middle of 2017, with a gap for physicians to adapt to the new policy. Every new policy needs ameliorate grooming and persistent education to reduce fluctuations in the charge per unit of copying and pasting and the initial delay of timely note completion.

In general, copy-and-paste features reduce the fourth dimension spent by physicians and let them to focus more on the patient'due south condition and on making judgments. Our study showed that restricting the use of copied-and-pasted text could reduce the rate of readmission for the same disease inside 14 days, with a ane-calendar month lag, and reduce the 3-day note completion charge per unit for months, without a long-term trend effect. Our research suggests that combined with an educational intervention, progress notes could exist more accurate, succinct, and efficient. This change could be harnessed to improve quality.

At that place are some limitations to our study. First, our retrospective data from ane medical middle in Taiwan require prospective research at multiple-level hospitals to expand its generalizability. Second, training programs persisted after the restriction, and skillful training and education will be needed subsequently future interventions in the employ of copying and pasting. All the same, evaluation data after grooming and education were not bachelor. Third, nosotros did non evaluate physicians' attitudes toward the new behavior and whether information technology immune them to spend more than time taking histories, performing physical examinations, checking reports and adjusting handling, nor did we detect a directly association with these behaviors. Restricting the use of the copy and paste function reduces the risk of errors, but there is the potential for personal key-in mistakes; nosotros did not assess the accuracy of notes that were not copied and pasted. Fourth, discharge evaluation and medication administration may touch readmission. Our hospital is a territory instruction infirmary in Taiwan, and physicians follow the principal rules of bear witness-based medicine. Additional research needs to be performed with a survey. Fifth, previous studies have institute that excessive copying and pasting prolonged the length of stay and increased bloodshed.^[7,28] In improver, the increase in the length of stay is amongst the factors that can increase costs.^[29] However, our written report did not show a significant effect of copying-and-pasting restrictions.

v Conclusions

This is the first written report to discuss restrictions of the copy-and-paste function in a Chinese hospital, thus broadening the focus of this issue across Western countries. The charge per unit of readmission for the same illness within 14 days was found to be related to the prevalence of copying and pasting in our study, with a 1-month lag. The prevalence of copying and pasting initially showed a decreasing trend for eleven months, followed by a short menstruation of a significantly increasing tendency and so stability subsequently the brake of copying and pasting. The rate of discharge summary annotation completion inside 3 days declined for months after the restriction of copying and pasting. The cost analysis of restricted copying and pasting needs to exist conducted in the futurity. More aggressive policies with adept education are needed to improve healthcare quality and timeliness of notes for future policy implementation in other countries.

Acknowledgments

The authors admit the support provided past TYAFGH_E_111054.

Writer contributions

Conceptualization: Ding-Chung Wu, Chun-An Cheng.

Data curation: Jui-Cheng Lu.

Formal analysis: Jui-Cheng Lu.

Funding acquisition: Chun-An Cheng.

Investigation: Ding-Chung Wu, Jui-Cheng Lu.

Methodology: Chia-Peng Yu.

Project assistants: Chun-An Cheng.

Resources: Chun-An Cheng.

Software: Chia-Peng Yu, Mei-Chuen Wang.

Supervision: Chun-An Cheng.

Validation: Ding-Chung Wu, Hong-Ling Lin.

Visualization: Chia-Peng Yu, Hong-Ling Lin, Mei-Chuen Wang.

Writing – original draft: Chun-Gu Cheng, Jui-Cheng Lu.

Writing – review & editing: Chun-An Cheng.

References

[1]. Ayaad O, Alloubani A, ALhajaa EA, et al. The function of electronic medical records in improving the quality of health care services: comparative report. Int J Med Inform 2019;127:63–7.

[2]. Kruse CS, Stein A, Thomas H, Kaur H. The utilize of electronic health records to support population health: a systematic review of the literature. J Med Syst 2018;42:214DOI: 10.1007/s10916-018-1075-half dozen.

• Cited Here |
• PubMed

[3]. Potato ZR, Wang J, Boland MV. Association of electronic health tape use above meaningful apply thresholds with hospital quality and safe outcomes. JAMA Network Open up 2020;three:e2012529–12012529.

• Cited Here

[4]. Lin H-L, Wu D-C, Cheng S-Grand, Chen C-J, Wang Mei-Chuen, Cheng C-A. Association betwixt electronic medical records and healthcare quality. Medicine 2020;99:e21182DOI: 10.1097/Doctor.0000000000021182.

[5]. Mamykina L, Vawdrey DK, Hripcsak K. How practise residents spend their shift time? A time and motion report with a detail focus on the apply of computers. Acad Med 2016;91:827DOI: 10.1097/ACM.0000000000001148.

[six]. Tsou AY, Lehmann CU, Michel J, Solomon R, Possanza L, Gandhi T. Rubber practices for copy and paste in the EHR. App Clin Computer science 2017;26:12–34.

• Cited Here

[7]. Singh H, Giardina TD, Meyer AN, Forjuoh SN, Reis MD, Thomas EJ. Types and origins of diagnostic errors in master intendance settings. JAMA Intern Med 2013;173:418–25.

[viii]. O'Donnell HC, Kaushal R, Barrón Y, Callahan MA, Adelman RD, Siegler EL. Physicians' attitudes towards re-create and pasting in electronic note writing. J Gen Intern Med 2009;24:63–8.

[9]. Weis JM, Levy PC. Copy, paste, and cloned notes in electronic wellness records. Chest 2014;145:632–8.

[10]. Kahn D, Stewart E, Duncan M, et al. A prescription for note bloat: an effective progress annotation template. J Infirmary Med 2018;13:378–82.

• Cited Here

[11]. Paterick ZR, Patel NJ, Paterick TE. Unintended consequences of the electronic medical record on physicians in training and their mentors. Postgrad Med J 2018;94:659–61.

[12]. Sheehy AM, Weissburg DJ, Dean SM. The role of copy-and-paste in the hospital electronic health record. JAMA Intern Med 2014;174:1217–8.

[thirteen]. Dean SM, Eickhoff JC, Bakel LA. The effectiveness of a bundled intervention to meliorate resident progress notes in an electronic health tape. J Hosp Med 2015;10:104–7.

[14]. Paterick ZR, Patel NJ, Ngo E, Chandrasekaran K, Jamil Tajik A, Paterick TE. Medical liability in the electronic medical records era. Proc (Bayl Univ Med Cent) 2018;31:558–61.

[15]. Turchin A, Goldberg SI, Breydo E, Shubina Thou, Einbinder JS. Copy/paste documentation of lifestyle counseling and glycemic control in patients with diabetes: true to course? Arch Intern Med 2011;171:1393–400.

[xvi]. Zhang M, Shubina Thousand, Morrison F, Turchin A. Following the money: copy-paste of lifestyle counseling documentation and provider billing. BMC Health Serv Res 2013;xiii:377DOI: 10.1186/1472-6963-13-377.

• Cited Here |
• PubMed

[17]. Winn W, Shakir IA, Israel H, Cannada LK. The role of copy and paste function in orthopedic trauma progress notes. J Clin Orthop Trauma 2017;8:76–81.

• Cited Here

[18]. Hribar MR, Rule A, Huang AE, et al. Back-up of progress notes for serial office visits. Ophthalmology 2020;127:134–5.

[19]. Monahan Grand, Ye C, Gould E, et al. Re-create-and-paste in medical student notes: extent, temporal trends, and relationship to scholastic performance. App Clin Informat 2019;10:479–86.

• Cited Hither

[xx]. Wang Md, Khanna R, Najafi Due north. Characterizing the source of text in electronic wellness tape progress notes. JAMA Intern Med 2017;177:1212–iii.

[21]. Wang Y, Liu S, Afzal N, et al. A comparing of word embeddings for the biomedical tongue processing. J Biomed Informat 2018;87:12–20.

• Cited Here

[22]. Lo Y-T, Chang C-Yard, Chen Thou-H, Hu F-West, Lu F-H. Factors associated with early 14-day unplanned hospital readmission: a matched case–control written report. BMC Health Serv Res 2021;21:01–11.

• Cited Here

[23]. Muggeo VM. Interval estimation for the breakpoint in segmented regression: a smoothed score-based arroyo. Australian New Zealand Journal of Statistics 2017;59:311–22.

[24]. Kuhn T, Basch P, Barr M, Yackel T. Clinical documentation in the 21st century: executive summary of a policy position paper from the American Higher of Physicians. Ann Intern Med 2015;162:301–3.

[25]. Ibach B, Stewart D, Chang R, Laing T. Epidemiology of re-create and pasting in the medical record at a third intendance academic medical centre. J Hosp Med 2012;7: (Suppl 2): 131.

• Cited Here

[26]. Thornton JD, Schold JD, Venkateshaiah L, Lander B. The prevalence of copied information past attendings and residents in critical care progress notes. Crit Care Med 2013;41:382DOI: 10.1097/CCM.0b013e3182711a1c.

[27]. Temple MW, Sisk B, Krams LA, Schneider JH, Kirkendall ES, Lehmann CU. Trends in utilise of electronic health records in pediatric office settings. J Pediat 2019;206:164–71.

[28]. Haugen H. Overcoming the risks of copy and paste in EHRs. J AHIMA 2014;85:54–5.

• Cited Hither |
• PubMed

[29]. Bayramlar OF. Cost Analysis of Device-associated Infections in a University Hospital. DOI:ten.13140/RG.two.2.28872.55045

• Cited Here

Keywords:

copy and paste; electronic wellness records; healthcare quality

Supplemental Digital Content

Copyright © 2022 the Writer(s). Published past Wolters Kluwer Health, Inc.

fergusonlitild.blogspot.com

Source: https://journals.lww.com/md-journal/Fulltext/2022/01280/Restricted_use_of_copy_and_paste_in_electronic.19.aspx

Share this post