A Practical Approach for Monitoring the Use of Copy-Paste in Clinical Notes.
| Autor: | Vawdrey DK; Geisinger Steele Institute for Health Innovation, Danville, PA.; Columbia University Department of Biomedical Informatics, New York, NY., Cauthorn C; Geisinger Steele Institute for Health Innovation, Danville, PA., Francis D; Geisinger Steele Institute for Health Innovation, Danville, PA., Hackenberg K; Geisinger Steele Institute for Health Innovation, Danville, PA., Maloney G; Geisinger Department of Medicine, Danville, PA., Hohmuth BA; Geisinger Steele Institute for Health Innovation, Danville, PA.; Geisinger Department of Medicine, Danville, PA. |
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| Jazyk: | angličtina |
| Zdroj: | AMIA ... Annual Symposium proceedings. AMIA Symposium [AMIA Annu Symp Proc] 2022 Feb 21; Vol. 2021, pp. 1178-1185. Date of Electronic Publication: 2022 Feb 21 (Print Publication: 2021). |
| Abstrakt: | The use of copy-paste in authoring clinical notes has been widely embraced by busy providers, but inappropriate copy-paste has been lambasted by critics for introducing risks related to patient safety and regulatory compliance. At an integrated academic health system with over 4,100 providers writing notes, we developed a pragmatic approach to assess the use of copy-paste. From January 1-December 31, 2020, approximately 2.3M inpatient notes and 6.6M ambulatory clinic notes were authored in our electronic health record. Of the inpatient notes, 42% used copy-paste, and 19% of overall note content was copied; in ambulatory notes, 18% used copy-paste and 12% of note content was copied. We describe an approach for including providers' copy-paste usage statistics into the ongoing professional practice evaluation process required for hospital accreditation, thereby offering individual training opportunities related to the lack of use of copy-paste or its potential overuse. (©2021 AMIA - All rights reserved.) |
| Databáze: | MEDLINE |
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