Does That Note Look Familiar To You? Copy-Paste And Other Woes Of Electronic Progress Notes

Electronic Health Record: In this descriptive study of electronic heath record (EHR) use by medicine interns at a US academic medical center, 32 interns were asked to write progress notes in a simulated version of an EHR (pre-populated with all the usual clinical data such as vital signs, laboratory results, prior discharge summaries, etc). The progress notes were assessed for recognition of clinical issues as well as use of data importation tools (macros) and copy-paste. About half the notes had copy-paste elements (defined as reproduction of an entire section of the plan without any modification), 65% imported 3 days of data into a daily progress note, and 68% of notes failed to list active medications. Data not included in the laboratory macro (such as TSH level or microbiology results) were more likely to be missed, with 55% failing to recognize that the patient’s organism was resistant to the prescribed antibiotic. Sadly, these findings may not be surprising to those who have looked at electronic progress notes recently — lengthy documents filled with information but void of meaning — but the findings do quantify and highlight some of the common errors that are easily facilitated by, or unable to be reduced by, EHR. — Sarang Kim, MD

Senior Resident Perspective: As electronic health records (EHR) grow increasingly ubiquitous in our nation’s hospitals and outpatient offices, the question being asked with louder concern is: Have they become a disservice to residents and interns-in-training?  A recent study of interns using a simulated EHR found that about half of notes had some copy-paste aspects and 68% did not include the patient’s active medications.  Without doubt, this practice is dangerous to patient care and damaging to resident education.  Too often, however, such critiques come embedded with deeper assumptions- that EHR’s themselves are to blame, and that such behavior is unique to the physicians of today.  It would seem then that the glow of yesteryear casts dim shade on the truth, which is that poor documentation is nothing new.  Surely we have not forgotten the spectacle of “chart-checking” rounds, with the entire team gathered squinting round a nearly illegible and clearly perfunctory hand-written note.  And what of clinic charts?  Too often they became bloated tomes collecting dust in a storeroom, years of information gathered on loose sheets, scribbled forms, even post-it notes.  Today, with a few keystrokes, I can find a specific laboratory result run nearly a decade ago.  I can easily cull recommendations from multiple specialists both on- and off-site, with remote access.  The fact of the matter is that bad behavior is common now, but just as it was common then.  Change will come with educating residents on the dangers of copy-paste, most importantly to their patients, but also in a medicolegal setting.  It will come with improving EHR’s ability to recognize and prevent copy-pasting.  And it will come with re-invigorating residents with a sense of pride in the necessary importance of the routine work they do, including yes, even that daily progress note. — Ahmed Khan, MD

March CA, Scholl G, Dversdal RK, Richards M, Wilson LM, Mohan V, Gold JA.,  Use of electronic health record simulation to understand the accuracy of intern progress notes. . JGME May 1, 2016, p237-239.

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