Mostly unrelated to Emergency Medicine – but an interesting descriptive study of a downstream phenomenon I see on a frequent basis.
For example, I'll intermittently follow-up a patient to see how they fared as an inpatient. I'll read the inpatient documentation, consultant reports, etc. – and find the tiny EM HPI perpetuated throughout the chart with minimal modification. This anecdotal experience is backed up by these authors who used text-compare software to identify copied passages in daily progress notes from an ICU setting. In this ICU at MetroHealth in Cleveland, 82% of resident notes copied at least >20% of the text from the previous days' progress note – and copied 55% of the prior content on average. Attending notes were slightly less frequently copied (74%), but tended to copy more content (61%).
There's no conclusive data regarding whether this copy/paste practice affects patient outcomes, but it's an interesting symptom of evolving medical care and documentation in the EHR era. I hope that, as HIT evolves, documentation tools trend towards encouraging concise, effective communication, rather than this sort of (likely ineffective) chart bloat.
"Prevalence of Copied Information by Attendings
and Residents in Critical Care Progress Notes"
www.ncbi.nlm.nih.gov/pubmed/23263617
