Winn Wesley, Shakir Irshad A, Israel Heidi, Cannada Lisa K
Department of Orthopaedic Surgery, Saint Louis University School of Medicine, 3635 Vista Avenue, 7th floor Desloge Towers, Saint Louis, MO, United States.
J Clin Orthop Trauma. 2017 Jan-Mar;8(1):76-81. doi: 10.1016/j.jcot.2016.04.002. Epub 2016 Apr 25.
The electronic medical record (EMR) is standard in institutions. While there is not concern for legibility of notes and access to charts, there is an ease of copy and paste for daily notes. This may not lead to accurate portrayal of patient's status. Our purpose was to evaluate the use of copy and paste functions in daily notes of patients with injuries at high risk for complications.
IRB approval was obtained for a retrospective review. Inclusion criteria included patients aged 18 and older treated at our Level 1 Trauma Center after implementation of Epic Systems Corporation, Verona, WI, USA. Those who were surgically treated for bicondylar tibial plateau fracture, or open tibial shaft fracture type I or II were included. Manual comparison of daily progress to the previous day's note was carried out. Comparisons were made by evaluating the subjective, objective, and plan portions of the notes, coded nominally using 1 for a change 0 for remaining the same.
38 patients' charts were reviewed during a 10-month (July 2012-April 2013) period, and the average length of stay was 12 days (range: 2-35). A total of 418 notes were compared. The overall average of copied data was 85% daily. In the subjective portion, 85-97% of the data was copied on a daily basis and 71-92% of the data was copied within the objective portion of the notes. There were 15 medical complications necessitating intervention. Of these medical complications, the note the day after the complication reflected the event in 10 out of 15, or 70%, of the complications. Thus 5, or 30%, of the patients did not have notes reflecting the complication ( < 0.05). There were 7 complications related to the injuries: 4 cases of compartment syndrome, 1 case of foot drop, representing a change in neurologic status, an amputation, and a wound infection treated with antibiotics. Four of the 7 complications (57%) were not reflected in the notes the following day after the complication ( < 0.05). There were 54 planned returns to the operating room for procedures, yet 30 of the 54 (56%) notes regarding planned surgical procedures notes did not accurately report the plan for surgery ( < 0.05). There were 4 patients with unplanned trips to the operating room and 3 of the notes (75%) did not reflect this ( < 0.05). Twelve patients (32%) did not have notes accurately reflecting discharge plans and/or destination ( < 0.05).
DISCUSSION/CONCLUSION: Our results demonstrated widespread use of copy and paste function. We encourage evaluation of the charts by comparing notes to check and a plan to minimize this practice. There needs to be consistent note writing guidelines and appropriate templates used. This will decrease the inaccuracies in the chart and provide a clear picture of the patient, their injuries, and current status.
电子病历（EMR）在医疗机构中已成为标准配置。虽然不用担心病历记录的可读性和查阅病历的便利性，但日常病历的复制粘贴操作却很容易。这可能无法准确反映患者的状况。我们的目的是评估在并发症高危受伤患者的日常病历中复制粘贴功能的使用情况。
本研究获得机构审查委员会（IRB）批准进行回顾性研究。纳入标准包括在美国威斯康星州维罗纳市Epic Systems Corporation系统实施后，在我们的一级创伤中心接受治疗的18岁及以上患者。纳入那些接受双髁胫骨平台骨折手术治疗，或I型或II型开放性胫骨干骨折手术治疗的患者。对每日病程记录与前一天的记录进行人工对比。通过评估记录的主观、客观和计划部分进行对比，将有变化的部分编码为1，保持不变的部分编码为0。
在2012年7月至2013年4月这10个月期间，共审查了38例患者的病历，平均住院时间为12天（范围：2 - 35天）。总共对比了418份病程记录。每日复制数据的总体平均比例为85%。在主观部分，每日复制的数据比例为85% - 97%，在病程记录的客观部分，复制的数据比例为71% - 92%。有15例医疗并发症需要干预。在这些医疗并发症中，并发症发生后次日的病程记录在15例中有10例（即70%）反映了该事件。因此，有5例（即30%）患者的病程记录未反映并发症情况（P < 0.05）。有7例并发症与损伤相关：4例骨筋膜室综合征，1例足下垂（代表神经状态改变），1例截肢，以及1例伤口感染并接受抗生素治疗。7例并发症中有4例（57%）在并发症发生次日的病程记录中未得到反映（P < 0.05）。有54例计划返回手术室进行手术，但在54例关于计划手术的病程记录中，有30例（56%）未准确报告手术计划（P < 0.05）。有4例患者非计划前往手术室，其中3例（75%）病程记录未反映这一情况（P < 0.05）。12例患者（32%）的病程记录未准确反映出院计划和/或目的地（P < 0.05）。
讨论/结论：我们的结果表明复制粘贴功能被广泛使用。我们鼓励通过对比病程记录来评估病历，并制定计划以尽量减少这种做法。需要有一致的病历书写指南并使用合适的模板。这将减少病历中的不准确之处，并清晰呈现患者及其损伤情况和当前状态。
