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Winn W, Shakir IA, Israel H, et al. The role of copy and paste function in orthopedic trauma progress notes. J Clin Orthop Trauma. 2016;8(1):76-81doi: 10.1016/j.jcot.2016.04.002.
Winn, W., Shakir, I. A., Israel, H., & Cannada, L. K. (2017). The role of copy and paste function in orthopedic trauma progress notes. Journal of clinical orthopaedics and trauma, 8(1), 76-81. https://doi.org/10.1016/j.jcot.2016.04.002
Winn, Wesley, et al. "The role of copy and paste function in orthopedic trauma progress notes." Journal of clinical orthopaedics and trauma vol. 8,1 (2017): 76-81. doi: https://doi.org/10.1016/j.jcot.2016.04.002
Winn W, Shakir IA, Israel H, Cannada LK. The role of copy and paste function in orthopedic trauma progress notes. J Clin Orthop Trauma. 2017 Jan-Mar;8(1):76-81. doi: 10.1016/j.jcot.2016.04.002. Epub 2016 Apr 25. PMID: 28360503; PMCID: PMC5359508.
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J Clin Orthop Trauma. 2017 Jan-Mar;8(1):76-81. doi: 10.1016/j.jcot.2016.04.002. Epub 2016 Apr 25.

The role of copy and paste function in orthopedic trauma progress notes.

Journal of clinical orthopaedics and trauma

Wesley Winn, Irshad A Shakir, Heidi Israel, Lisa K Cannada

Affiliations

  1. Department of Orthopaedic Surgery, Saint Louis University School of Medicine, 3635 Vista Avenue, 7th floor Desloge Towers, Saint Louis, MO, United States.

PMID: 28360503 PMCID: PMC5359508 DOI: 10.1016/j.jcot.2016.04.002

Abstract

INTRODUCTION: 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.

METHODS: 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.

RESULTS: 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 (

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.

Keywords: Copy; Copy–paste; EMR; Electronic medical record; Orthopedic surgery; Paste; Trauma

References

  1. JAMA Intern Med. 2014 Aug;174(8):1217-8 - PubMed
  2. Crit Care Med. 2013 Feb;41(2):382-8 - PubMed
  3. AMIA Annu Symp Proc. 2010 Nov 13;2010:622-6 - PubMed
  4. J Hosp Med. 2015 Feb;10(2):104-7 - PubMed
  5. JAMA. 2006 May 24;295(20):2335-6 - PubMed
  6. Appl Clin Inform. 2013 Jun 26;4(2):293-303 - PubMed
  7. Am J Med. 2009 Jun;122(6):495-6 - PubMed
  8. Med Care. 2010 Nov;48(11):981-8 - PubMed
  9. J Biomed Inform. 2005 Aug;38(4):264-6 - PubMed
  10. CMAJ. 2013 Dec 10;185(18):E826 - PubMed
  11. Ann Intern Med. 2010 Nov 16;153(10):671-7 - PubMed
  12. BMC Med Inform Decis Mak. 2013 Aug 01;13:81 - PubMed
  13. J Gen Intern Med. 2009 Jan;24(1):63-8 - PubMed
  14. Int J Med Inform. 2007 Jun;76 Suppl 1:S122-8 - PubMed
  15. Perspect Health Inf Manag. 2013 Oct 01;10:1c - PubMed
  16. Med Care. 2010 Mar;48(3):203-9 - PubMed
  17. N Engl J Med. 2008 Apr 17;358(16):1656-8 - PubMed
  18. J AHIMA. 2014 Jun;85(6):54-5 - PubMed
  19. Ann Intern Med. 2006 May 16;144(10):742-52 - PubMed
  20. Chest. 2014 Mar 1;145(3):632-8 - PubMed

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