Geisinger Steele Institute for Health Innovation, Danville, PA.
Columbia University Department of Biomedical Informatics, New York, NY.
AMIA Annu Symp Proc. 2022 Feb 21;2021:1178-1185. eCollection 2021.
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.
在撰写临床记录时，使用复制粘贴已被忙碌的医生广泛接受，但不适当的复制粘贴因引入与患者安全和法规遵从性相关的风险而受到批评。在一个拥有超过 4100 名医生的综合性学术医疗系统中，我们开发了一种实用的方法来评估复制粘贴的使用情况。在 2020 年 1 月 1 日至 12 月 31 日期间，我们的电子病历中共撰写了约 230 万份住院记录和 660 万份门诊诊所记录。在住院记录中，有 42%使用了复制粘贴，有 19%的记录内容是复制的；在门诊记录中，有 18%使用了复制粘贴，有 12%的记录内容是复制的。我们描述了一种方法，可以将医生的复制粘贴使用统计数据纳入医院认证所需的持续专业实践评估过程中，从而为缺乏使用复制粘贴或可能过度使用复制粘贴的情况提供个人培训机会。
