Most physicians are taking advantage of the copy and paste function in their electronic health records and copying progress notes rather than creating new, original ones, according to a new study published in the journal Critical Care Medicine.
The study examined 2,068 progress notes by 62 residents and 11 attending physicians of 135 intensive care unit patients in a medical center in Cleveland, using plagiarism detection software. The researchers found that more than four-fifths (82 percent) of the residents and three-fourths (74 percent) of the attendings' notes contained at least 20 percent of copied information. While the residents authored more copied notes, they copied a bit less information than the attendings (55 percent to 61 percent).
After a day or more off, a whopping 94 percent of the attendings copied from their own prior notes, and two-thirds (66 percent) of the residents did so.
The concern about the prevalence of the note copying is that copying and pasting old and potentially out of date information could impact patient care and/or make the medical records "indecipherable," according to a recent Reuters article. The article also noted that electronic copying could signify a shift from the use of progress notes as a means to communication to billing documentation purposes.
Government officials and others have expressed concern that EHR shortcuts and other tools are causing providers to engage in improper billing. Others have claimed that the electronic functions are actually capturing more accurate billing and that the shortcuts reduce physicians' burdens.