Study: 46 Percent of Progress Note Text is Copy and Pasted

A study exploring the prevalence of copy and pasted text in EHR progress notes found that in one hospital, 46 percent of the text in notes was copy and pasted. Additionally, the study of 23,630 total records found that 36 percent of progress note text was imported, while only 18 percent of the text was entered manually.

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EHR Management Track Discusses Human Error Challenges

To err is human, but to really foul things up, you need a computer. So stated the introductory slide for the convention session “To Err is Human…To Correct Takes an HIM Professional” presented by Mary Jedlicka, RHIT, and Nick Judd, MBA, RHIA, from the Cleveland Clinic Health System.

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An Appropriate Use of Copy Forward, with a Caveat

In a June print story on bad documentation practices in electronic health records, Stephen Levinson, MD, warns against poorly designed systems that encourage busy physicians to copy old information forward with a single click, speeding them past performing and documenting care. Copying forward a previous review of systems without reviewing changes in the patient’s status, for example, is noncompliant and potentially fraudulent,...

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