Inpatient Progress Note Content Often Cut and Pasted

Share this content:
Inpatient Progress Note Content Often Cut and Pasted
Inpatient Progress Note Content Often Cut and Pasted

WEDNESDAY, June 7, 2017 (HealthDay News) -- Less than 20 percent of progress note content is entered manually by medical students, residents, and direct care hospitalists, according to a research letter published online May 30 in JAMA Internal Medicine.

Michael D. Wang, M.D., from the University of California, San Francisco, and colleagues used a new electronic health record (EHR) tool to evaluate documentation practices by medical students, residents, and direct care hospitalists. Using the EHR tool, they examined the provenance of every character to see whether it was typed fresh (manually entered), pulled in from another source (imported), or pasted from elsewhere (copied). A total of 23,630 inpatient progress notes written by 460 clinicians were analyzed over an eight-month period.

The researchers found that, compared with medical students or direct care hospitalists, residents manually entered less (11.8 versus 16.2 and 14.1 percent of the text, respectively) and copied more (51.4 versus 49.0 and 47.9 percent, respectively). Notes were shortest for direct care hospitalists (5,006 characters) compared with medical students and residents (7,053 and 6,720 characters, respectively).

"Clinicians spend time every day writing progress notes," the authors write. "Understanding their practice and the needs of their audience could spur improvements that restore the utility of this documentation."

One author disclosed financial ties to Digital Health Innovation, and reported being the principal inventor of CareWeb.

Abstract/Full Text (subscription or payment may be required)

Share this content:

is free, fast, and customized just for you!

Already a member?

Sign In Now »


Sign up for myCME e-newsletters


Drug Lookup

Browse drugs by: BrandGenericDisease

Trending Activities

All Professions

More in Home

FDA: Potential Contamination in Some Liquid Pharma Products

FDA: Potential Contamination in Some Liquid Pharma Products

Concerns over possible bacterial contamination that could cause severe infections in vulnerable patients

Electrotherapy, Acupuncture Ease Post Knee Arthroplasty Pain

Electrotherapy, Acupuncture Ease Post Knee Arthroplasty Pain

Meta-analysis shows drop in use of opioids for electrotherapy; delayed opioid use with acupuncture

Frequency, Degree of Pubic Hair Grooming Linked to Injury Risk

Frequency, Degree of Pubic Hair Grooming Linked to ...

Men and women who removed all their pubic hair 11 times during their life had increased risk for injury

is free, fast, and customized just for you!

Already a member?

Sign In Now »