The electronic health record (EHR) is recognized as a key component of the modern practice of medicine. Despite numerous advantages, EHR have enabled frequent copypaste events (CPE). While previous studies show that CPE occur in up to 54% of progress notes, the significance of these CPE is unclear. We hypothesized that the frequency and location of CPE by physicians on the same service would differ from CPE created by physicians.
All physiciangenerated notes for patients admitted to a general medicine service in a single year were included. Notes associated with 12 random patients were compared in a pairwise fashion on a linebyline level for CPE using a Microsoft Access database. False CPE (e.g. generic signatures and templates) were identified and removed. All CPE were then categorized and quantified into components of notes (e.g. physical exam, labs, impression, plan). Chisquared and Fisher’s exact were used for statistical analysis comparing location of CPE based upon provider and service, with different service, different provider CPE as our baseline.
We observed a total of 57,125 CPE in 299 documents from our 12 patients. After we removed 46815 false CPE, 229 (76.6%) documents remained, containing 10,310 (18.0%) CPE. 1754 note components were copied, 1062 (60.5%) by the same provider on the same service, 562 (32.0%) by different providers on the same service (e.g. transition from one hospitalist to the next) and 127 (7.2%) by different providers on different services (e.g. between a consult and primary service). The location of CPE differed depending upon service. The comparative distributions of intra and interprovider CPE components generated from the same service were as follows: significant (16.7% vs. 17.3%) and insignificant (21.0% vs. 24.6%) portions of the plan; physical exam (24.9% vs. 19.4%); assessment (15.5% vs. 22.8%); and labs/studies (11.8% vs. 6.9%). The most common, interprovider CPE components from different services were: lab/study (39.4%); insignificant portions of the plan (28.3%); past medical history (8.7%); and medications (6.3%). Interservice, interprovider CPE were significantly less frequent than intraservice CPE in physical exam, significant portions of the plan and assessment (P < 0.001 for all).
CPE between physicians on different services are the most infrequent and differ substantially in the location of such events compared to CPE on the same service. CPE are likely to occur for different reasons between services versus within a service, which should be considered in future approaches in the evaluation of CPE.
To cite this abstract:Ibach B, Stewart D, Chang R, Laing T. Epidemiology of Copy and Pasting in the Medical Record at a Tertiarycare Academic Medical Center. Abstract published at Hospital Medicine 2012, April 1-4, San Diego, Calif. Abstract 97673. Journal of Hospital Medicine. 2012; 7 (suppl 2). https://www.shmabstracts.com/abstract/epidemiology-of-copy-and-pasting-in-the-medical-record-at-a-tertiarycare-academic-medical-center/. Accessed September 18, 2019.