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

A study exploring the prevalence of copy and pasted text in electronic health record (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.

As experts at AHIMA have warned, copy and pasting EHR text can lead to errors such as outdated information, unnecessarily lengthy progress note information, and the propagation of false information, but physicians and documenters continue to do so because it can save time. That was one of the findings for researchers at the University of California San Francisco Medical Center, which analyzed records stored in the university medical center’s Epic software. The software allowed researchers to see which parts of a note of were manually entered, copied, or imported.

The study also broke down copy and paste rates among residents, medical students, and direct care hospitalists. Investigators found that among direct care hospitalists 47.9 percent of the average note was copied; for residents, 51.4 of notes were copied and 11.8 percent were manually entered. Medical students copied 49 percent of the progress note and manually entered 16.2 percent, a MedCity News analysis of the study showed.

“Although we conducted a single-center, single-service analysis, we observed patterns that were consistent with what has been measured in previous studies and what clinicians have observed anecdotally,” investigators wrote. “…This finding could spur EHR design that makes copied and imported information readily visible to clinicians as they are writing a note but, ultimately does not store that information in the note.”

The study was published in JAMA Internal Medicine.

Mary Butler is the associate editor at The Journal of AHIMA.

1 Comment

  1. Copy and paste of medical records is not the most accurate way to share medical information

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