Peer Review Sources From Ahima on Copy and Pasting in Ehrs

1 Introduction

Medical records refer to patient records that capture diverse conditions, examinations, differential diagnoses and treatment plans performed past medical providers engaged in medical services. Electronic wellness records (EHRs) are stored on a computer, and computer operating systems provide many user-friendly functions, such as copying and pasting, which can save fourth dimension. EHRs are unlike from other electronic files because they record the patient's condition and adjustments to treatment.

The widespread adoption of EHRs has led to meaning progress in the modernization of healthcare delivery. According to health provider surveys, EHR adoption can meliorate healthcare compared with paper-based medical records.^[1] Physicians utilize EHRs to completely, succinctly, accurately and quickly certificate a patient's condition for their own use and their colleagues' use. The benefits of EHRs include improved access to records, the facilitation of communication, increased quality of patient-centered care through clinical decision back up and safety engineering, cost savings, and improved information management for medical research and didactics.^[ii,3] In a previous study, 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 stage.^[4]

Medical documentation has evolved with the rapid growth in the apply of EHRs. Physicians spend 26% of their time on clinical documentation and 18% of their time writing on computers.^[5] The terms "cutting" and "paste" were originally coined in reference to the concrete process of cut and pasting paragraphs between different locations during the process of manuscript editing. Nigh all EHR software allows for information to be moved from nearly any function of a patient'southward record to some other section. The results of by study indicate that the majority of physicians work on EHRs, and the review demonstrated that seven.4% of index 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 charge per unit due to the use of the copy-and-paste function is approximately 2.6%,^[7] but a significant affect on patient safety issues was not found.^[6,8] Using copying and pasting can save time, allowing physicians to focus on addressing the current illness and making adjustments. In the fast-paced medical earth, EHRs sanction copying and pasting with give-and-take templates and embedded problem lists. The discussion template of new medical notes was compared with previous notes by the text check method with a threshold of similarity to the restricted use of copying and pasting. However, copying and pasting can cause data integrity issues due to unnecessarily long entries, poor organisation, less accurate encounter tracking of medical atmospheric condition, inferred communication among users, diagnosis errors induced past fake assumptions or attribution of authorship, and regulatory concerns about the accurateness and medical necessity of billed services.^[9–xiv] The negative consequences for physicians are apparent; thus, the effects of technological efficiency must be re-evaluated. This approach risks overlooking new or changing information and allows the perpetuation of prior inaccuracies.^[xiv] Inferior physicians in training may not learn how to take an accordingly detailed history, conduct a physical examination, collaborate with patients and family, or construct a broad differential idea process.^[11]

In that location are some controversial views about the apply of the copy-and-paste function. This part was non found to be associated with glucose control when information virtually lifestyle counseling was copied, and its use led to poorer results in evaluations and management.^[15,16] Orthopedic trauma was repeated in 85% of inpatient records^[17] and in 75% of outpatient ophthalmology records.^[18] A previous study has shown that an intervention with note-writing guidelines tin can improve questions about the quality of EHRs but cannot influence the results of copying and pasting.^[13]

Internal institutional policies should be created along with best practices to restrict the use of the copy-and-paste office. 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 teaching and the conscientious monitoring of notes. Bloated notes containing inaccuracies and oversights are regarded as dangerous, inefficient, and unprofessional. The inappropriate use of copying and pasting should exist viewed as a patient safety issue.^[nine] Longer notes could lead to reader fatigue. One written report showed a negative relationship between medical student performance and longer documentation.^[xix]

Nosotros hypothesize that advanced restrictions on the utilise of the re-create-and-paste office have the potential to affect inpatient healthcare quality and influence timely notation completion. Physicians may overrely on the copy-and-paste role to meet timeline goals, and they must perform articulate history taking and physical examinations with accurate adjustments and optimal treatments.

2 Materials and methods

This retrospective observational written report 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 center that provides third service in northern Taiwan. To preclude the overdocumentation of clinical notes, the infirmary designed internal policies and identified the percent 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 note was copied and pasted was restricted to 70% similarity to previous documents using natural language programming and text mining^[20,21] starting in July 2016 at the Tri-Service Full general Hospital. If the similarity was more than than 70%, the estimator would not salvage the progress annotation, like to a plagiarism detection checker. This study explored the correlation between the prevalence of copied-and-pasted text, healthcare quality and timely documentation completion status.

The 14-twenty-four hour period readmission rate, length of stay and inpatient mortality rate were evaluated to mensurate healthcare quality. The 14-day readmission data were obtained from a discharge dataset of patients with the aforementioned diagnosis based on comparing the discharge date of the focal access with the next admission within a 14-mean solar day period. The 14-mean solar day readmission charge per unit was the number of readmission cases inside 14 days divided by the discharge survival cases. The readmission charge per unit was related to inpatient medical care, discharge family care, and inpatient healthcare quality and was surveyed in past studies.^[22] The discharge summary note is a summary of the patient's history, examinations, treatments and belch plan, and its timely completion supports medical provider advice 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 discharge summary note completion inside 3 days. To understand the trend of the prevalence of copying and pasting afterwards the restricted utilize of copying and pasting was implemented, scenarios were based on breakpoints using segmented regression 11.96 months and 15 months after policy implementation (Supplementary Digital Content Figure, https://links.lww.com/MD2/A856 Segmented regression of the prevalence of copying and pasting after policy implementation). Four stages were identified co-ordinate 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 restriction implementation: the premonitoring phase (January 2016–June 2016); scenario 1, descending phase (July 2016–May 2017); scenario 2, ascending phase (June 2017–September 2017); and scenario 3, fluctuation phase (September 2017–December 2018). The flowchart for this study is shown in Figure 1. The study was approved past TSGH IRB 1-108-05-179 (ethical approval date: November eleven, 2019).

Figure 1:

The flowchart of the protocol of this study.

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

The prevalence of copied-and-pasted text, the rate of discharge summary note completion inside iii days, and inpatient mortality (Shapiro–Wilk test: 0.403, 0.678, 0.083, 0.344) were fitted as normally distributed. The rate of readmission within 14 days (Shapiro–Wilk < 0.001) was not fitted as commonly 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 after implementation of the restriction policy, the segmented package in R was used.^[23] The rates of the discharge summary annotation being completed within iii days in the different mail service-restriction scenarios were compared with those in the pre-restriction period. We performed a multifractal cantankerous-correlation analysis of the rate of readmission for the same disease within 14 days compared with the prevalence of copied-and-pasted text to calculate the lag time betwixt the time series, and the highest correlation coefficient was selected. Poisson regression was performed to assess the relative upshot of the re-create-and-paste brake policy on the 14-day readmission rate with a 1-month lag or discharge note completion charge per unit within 3 days. The assay was performed with IBM SPSS Statistics for Windows, Version 22.0 (IBM Corp., Armonk, NY).

3 Results

In that location were a total of 142,039 patients with 167,736 medical records in this study. The average numbers of annual discharges were approximately 25,561 and 14,967 for internal medicine and surgery, respectively, from 2016 to 2018. The annual average discharge number was approximately 2168 in gynecology and obstetrics, approximately 1697 in pediatrics, approximately 1727 in otorhinolaryngology and approximately 1188 in ophthalmology. We 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), later monitoring. The overall charge per unit of readmission for the same disease within fourteen days was reduced from 3.46 ± 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 note completion within 3 days decreased from 93.73 ± i.39% to 91.77 ± ane.67% (P = .011) after monitoring. Withal, the length of stay and inpatient mortality were not significantly dissimilar (Table 1).

Table 1 - The characteristics of the pre-monitoring and mail service-monitoring periods for copying and pasting.

	Prerestriction (SD) 26326	Postrestriction (SD) 141410	P
Prevalence of copy and paste (%)	35.72 (v.53)	23.71 (vi.9)	.001∗
14-day readmission rate (%)	3.46 (0.43)	1.5 (1.03)	<.001∗
Internal medicine (%)	four.57 (0.48)	two.01 (1.15)	<.001∗
Surgery (%)	2.39 (0.5)	1.01 (0.88)	<.001∗
GYN and OBS (%)	3.94 (1.85)	i.09 (ane.07)	.011∗
Pediatric (%)	0.53 (0.45)	0.24 (0.32)	.191
Otolaryngology (%)	ane.68 (i.07)	0.43 (0.72)	.033∗
Inpatient mortality (%)	ii.70 (0.43)	2.75 (0.31)	.764
Length of stay (days)	6.vi (seven.88)	6.68 (7.89)	.983
The rate of discharge summary note completion inside 3 d (%)	93.73 (ane.39)	91.77 (1.67)	.011∗
Case mix index	1.2 (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 xi.96 months and 15 months subsequently policy implementation. Postrestriction scenario 1 showed that the prevalence of copying and pasting decreased (slope: −ane.459%/calendar month). Then, the prevalence of copying and pasting increased (gradient: 2.807%/month) in postrestriction scenario 2, followed by fluctuations (gradient: −0.546%/month) in postrestriction scenario three. The decreasing trend with a relative chance (RR) every month was 0.979 (95% conviction interval [CI]: 0.963–0.996, P = .015) during the premonitoring stage with prepolicy education. The decreasing trend with RR was 0.977 (95% CI: 0.966–0.989, P = .002) during scenario 1 later brake. The increasing tendency with RR was ane.077 (95% CI: 0.997–i.163, P = .054) during scenario two later on brake. The decreasing trend with RR was 0.992 (95% CI: 0.972–1.012, P = .396) during scenario 3 later on 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 afterward restriction; 35.72 ± 5.53 vs 22.83 ± five.57 (P = .01) during scenario 2 after restriction; and 35.72 ± 5.53 vs 21.8 ± vii.57 (P < .001) during scenario 3 after restriction. The readmission charge per unit for the same disease within xiv days decreased from 3.46 ± 0.43 to ii.68 ± 0.81 (P = .02) until 11 months of restriction (Fig. 2). The highest 3-day note completion rate was 95.8% in April 2016, and the lowest was 87.6% in May 2017 (Fig. 3). The subtract in the charge per unit of three-day discharge summary note completion after monitoring continued until May 2017 (93.73 ± 1.39% vs ninety.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 same illness within 14 days.

Figure 3:

The charge per unit of discharge summary note completion within 3 days.

Table 2 - The deviation in the post-restricted scenario compared with the prerestricted stage using bonferroni correction for multiple comparisons.

	Prevalence of copy and paste		14-day readmission charge per unit		3-day completion rate
Stage	Hateful ± SD	P	Hateful ± SD	P	Hateful ± SD	P
Prerestricted	35.72 ± 5.53		3.46 ± 0.43		93.73 ± ane.39
Postrestricted scenario one	26.62 ± 5.78	.009∗	2.68 ± 0.81	.02∗	90.59 ± 1.62	.001∗
Postrestricted scenario 2	22.83 ± v.57	.01∗	0.86 ± 0.12	<.001∗	91.76 ± 1.48	.078
Postrestricted scenario iii	21.8 ± 7.57	<.001∗	0.81 ± 0.15	<.001∗	92.64 ± ane.25	.thirteen

SD = standard deviation.

^∗ P < .05.

The prevalence of copied-and-pasted text was related to the rate of readmission for the aforementioned affliction within 14 days, with a 1-month lag (cross-correlation coefficient = 0.616). The RR of 1.105 (95% CI: one.064–1.147, P < .001) of the 14-mean solar day readmission rate was affected by the prevalence of copying and pasting, with a 1-month lag. The RR of one.043 (95% CI: 0.971–ane.119, P = .248) of the discharge annotation completion charge per unit was affected by the prevalence of copying and pasting.

4 Word

According to this time-series report, the rate of readmission for the same disease within 14 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 grooming and educational activity are needed to reduce the increasing prevalence of copying and pasting. The rate of discharge summary note completion inside three days was college before the re-create-and-paste intervention. After restriction of the copy-and-paste procedure, the timely completion charge per unit decreased for several months. This report tin can contribute to the understanding of changes in the prevalence of text copying and pasting in medical records, enhance patient intendance and reduce the learning period for timely notation completion.

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

EHRs in paradigm reports take 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 take been utilized since 2017. Our previous study found that healthcare quality, including inpatient mortality and the length of stay showed no significant changes betwixt partial (2015–2016) and full EHR (2017–2018) stages,^[four] simply healthcare quality must be farther improved with EHR adoption after 2015. Importing technology such every bit copying and pasting is common, useful and convenient for documentation and clinical notes, simply its use in clinical documentation is controversial. The advantages of using the re-create-and-paste part include the efficiency in information capture, improved timeliness, legibility, consistency, completeness, communication, and positive payment and consequence measures. Nonetheless, excessive utilise can pb to the recording of inaccurate or outdated information about patients. This is an important effect that requires improvement. Excessive use of copied and pasted text in EHRs can increment the efficiency of patient care only tin also touch on patient safe and present legal and upstanding issues. It may also lead to the introduction of inaccurate information and oversights in the patient records, poor communication of the patient's current status, and subsequent diagnostic inaccuracies and a reduction in patient safety.^[nine]

Physicians may overrely on the re-create-and-paste function to run across timeline goals. Physicians spend 26% of their time on clinical documentation and 18% of their fourth dimension writing on computers. Copying and pasting tin can relieve time, allowing physicians to focus on addressing the current illness 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 applied solution needs to be developed, and identifying the pct 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 commencement of the 3rd quarter of 2016 afterwards the intervention had a specially noticeable change: the prevalence persistently decreased to the lowest annual average of 21.82% in 2018. The trends showed a 2.1% decrease per month in the premonitoring phase, a 1.459% subtract per month in scenario 1 later brake, and a 0.546% decrease per month in scenario iii after brake. In a previous report that analyzed cess and treatment plans in the intensive care unit during 2009, xx% of the text in 82% of notes from residents and 74% of notes from attending physicians was found to include copied data.^[26] We plant that the prevalence of copied-and-pasted text was 40% before the brake and decreased to less than twenty% each year after the restriction policy was implemented. A good text mining tool for identifying duplications and adequate policies could reduce the prevalence of duplications. There were ii peaks: in 2018, during the Chinese New year, when fewer medical providers were nowadays during the holiday in February, and at the time 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 illness within 14 days showed a decreasing tendency twelvemonth by 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 proficient patient–dr. relationships and in-depth knowledge of EHRs. The rates in pediatrics did not change after the intervention, potentially due to greater complexities in pediatric patient care and pediatricians investing more time in caring for patients. A previous study showed that EHRs are non related to quality in the pediatric section.^[27]

Because the policy induced reduced copying and pasting at first, doctors adapted to the policy. The hospital monitored the similarity rate and implemented promotional education to let the similarity rate stabilize. With the establishment of the mechanism of prevention of copying and pasting in the tertiary quarter of 2016, the institute controlled the prevalence of copied-and-pasted text using natural language programming and text mining. Considering of the need to adjust at the initial stage of implementation, there was initially a reduction in the prevalence of copied-and-pasted text and a decline in the timely completion rate of medical records. The adaptation period after 11 months showed a cursory ascending trend, followed by stability. The timely annotation completion rate showed a decline following the restriction and so recovered in the center of 2017, with a gap for physicians to suit to the new policy. Every new policy needs amend training and persistent education to reduce fluctuations in the rate of copying and pasting and the initial delay of timely note completion.

In general, copy-and-paste features reduce the fourth dimension spent past physicians and let them to focus more on the patient's condition and on making judgments. Our written report showed that restricting the utilize of copied-and-pasted text could reduce the rate of readmission for the aforementioned disease within xiv days, with a i-month lag, and reduce the 3-twenty-four hours note completion rate for months, without a long-term trend consequence. Our research suggests that combined with an educational intervention, progress notes could be more accurate, succinct, and efficient. This change could be harnessed to improve quality.

At that place are some limitations to our report. Outset, our retrospective data from 1 medical center in Taiwan require prospective research at multiple-level hospitals to aggrandize its generalizability. 2d, training programs persisted subsequently the brake, and proficient grooming and didactics will exist needed later future interventions in the use of copying and pasting. Notwithstanding, evaluation data after training and education were non available. Third, we did not evaluate physicians' attitudes toward the new behavior and whether it allowed them to spend more time taking histories, performing physical examinations, checking reports and adjusting handling, nor did we discover a direct association with these behaviors. Restricting the use of the re-create and paste function reduces the risk of errors, only there is the potential for personal key-in mistakes; nosotros did not appraise the accuracy of notes that were not copied and pasted. Fourth, discharge evaluation and medication assistants may affect readmission. Our hospital is a territory teaching hospital in Taiwan, and physicians follow the primary rules of evidence-based medicine. Additional research needs to be performed with a survey. Fifth, previous studies accept found that excessive copying and pasting prolonged the length of stay and increased mortality.^[7,28] In addition, the increment in the length of stay is among the factors that tin can increase costs.^[29] However, our study did non bear witness a significant effect of copying-and-pasting restrictions.

5 Conclusions

This is the get-go study to talk over restrictions of the re-create-and-paste function in a Chinese infirmary, thus broadening the focus of this issue beyond Western countries. The rate of readmission for the same illness within 14 days was plant 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 tendency for xi months, followed by a short period of a significantly increasing trend and then stability later on the brake of copying and pasting. The rate of discharge summary note completion within iii days declined for months afterwards the brake of copying and pasting. The cost analysis of restricted copying and pasting needs to be conducted in the future. More ambitious policies with good education are needed to improve healthcare quality and timeliness of notes for hereafter policy implementation in other countries.

Acknowledgments

The authors admit the support provided by TYAFGH_E_111054.

Author contributions

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

Data curation: Jui-Cheng Lu.

Formal analysis: Jui-Cheng Lu.

Funding conquering: Chun-An Cheng.

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

Methodology: Chia-Peng Yu.

Projection administration: Chun-An Cheng.

Resource: 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 typhoon: Chun-Gu Cheng, Jui-Cheng Lu.

Writing – review & editing: Chun-An Cheng.

References

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

[ii]. Kruse CS, Stein A, Thomas H, Kaur H. The use of electronic health records to back up population wellness: a systematic review of the literature. J Med Syst 2018;42:214DOI: x.1007/s10916-018-1075-6.

• Cited Here |
• PubMed

[3]. Murphy ZR, Wang J, Boland MV. Association of electronic health record employ above meaningful utilise thresholds with hospital quality and safety outcomes. JAMA Network Open up 2020;iii:e2012529–12012529.

• Cited Here

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

[5]. Mamykina 50, Vawdrey DK, Hripcsak G. How do residents spend their shift time? A time and motion written report with a particular focus on the utilize of computers. Acad Med 2016;91:827DOI: 10.1097/ACM.0000000000001148.

[vi]. Tsou AY, Lehmann CU, Michel J, Solomon R, Possanza L, Gandhi T. Safety practices for re-create and paste in the EHR. App Clin Informatics 2017;26:12–34.

• Cited Here

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

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

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

[10]. Kahn D, Stewart East, Duncan One thousand, et al. A prescription for notation bloat: an effective progress note template. J Hospital Med 2018;13:378–82.

• Cited Here

[xi]. Paterick ZR, Patel NJ, Paterick TE. Unintended consequences of the electronic medical tape 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.

[13]. Dean SM, Eickhoff JC, Bakel LA. The effectiveness of a arranged intervention to improve resident progress notes in an electronic health record. J Hosp Med 2015;10:104–vii.

[xiv]. Paterick ZR, Patel NJ, Ngo E, Chandrasekaran G, 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 Eastward, Shubina M, Einbinder JS. Copy/paste documentation of lifestyle counseling and glycemic control in patients with diabetes: truthful to grade? Arch Intern Med 2011;171:1393–400.

[16]. Zhang M, Shubina 1000, Morrison F, Turchin A. Following the coin: copy-paste of lifestyle counseling documentation and provider billing. BMC Health Serv Res 2013;13:377DOI: 10.1186/1472-6963-xiii-377.

• Cited Here |
• PubMed

[17]. Winn Due west, Shakir IA, State of 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 Hither

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

[xix]. Monahan K, Ye C, Gould Due east, et al. Copy-and-paste in medical student notes: extent, temporal trends, and relationship to scholastic functioning. App Clin Informat 2019;x:479–86.

• Cited Here

[20]. Wang MD, Khanna R, Najafi Due north. Characterizing the source of text in electronic health record progress notes. JAMA Intern Med 2017;177:1212–iii.

[21]. Wang Y, Liu S, Afzal North, et al. A comparison of discussion embeddings for the biomedical natural linguistic communication processing. J Biomed Informat 2018;87:12–twenty.

• Cited Here

[22]. Lo Y-T, Chang C-M, Chen M-H, Hu F-W, Lu F-H. Factors associated with early 14-24-hour interval unplanned hospital readmission: a matched case–control study. BMC Health Serv Res 2021;21:01–11.

• Cited Hither

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

[24]. Kuhn T, Basch P, Barr Thousand, 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–iii.

[25]. Ibach B, Stewart D, Chang R, Laing T. Epidemiology of copy and pasting in the medical record at a tertiary care academic medical centre. J Hosp Med 2012;seven: (Suppl 2): 131.

• Cited Here

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

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

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

• Cited Here |
• PubMed

[29]. Bayramlar OF. Cost Analysis of Device-associated Infections in a Academy Hospital. DOI:10.13140/RG.2.2.28872.55045

• Cited Here

Keywords:

copy and paste; electronic health records; healthcare quality

Supplemental Digital Content

Copyright © 2022 the Author(due south). Published by Wolters Kluwer Wellness, Inc.

schwabcating1995.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