PURPOSE: Electronic medical records (EMRs) have been touted for their potential to improve health care quality and safety. Daily progress notes allow physicians to communicate their care plans. With EMRs, daily progress notes may include more information and therefore improve care. However, ease of note copying with EMRs may impede care. We sought to identify the prevalence of copying in daily ICU progress notes.
METHODS: We reviewed the EMRs of patients admitted to the ICU on consecutive days over 1 month who had > 72 hour ICU lengths of stay. 480 progress notes of 30 patients were reviewed. Each day for a given patient, the assessments and plans of progress notes written by residents and attendings were compared with the assessments and plans of progress notes written by the same physician on the day prior. The attending and resident assessments and plans were also compared to each other. Copyfind(tm) software was used for all comparisons. The proportion copied was the ratio of the number of duplicate groups of 3 words in the current and prior assessments and plans to the total number of words in the prior assessments and plan. The average proportion of copying was determined for each physician.
RESULTS: Residents and attendings copied an average of 66±18% and 66±21% of their own assessments and plans respectively (P=1). Residents copied attendings’ assessments and plans 15±10% of the time and attendings copied residents’ assessments and plans 19±9% of the time (P<0.001). After a new resident or attending assumed care, the amount of copying decreased to 52±2% and 22±10% respectively (P<0.001).
CONCLUSION: In this preliminary study, both residents and attendings frequently copied their own assessments and plans. However, when new physicians assumed care, copying between physicians decreased.
CLINICAL IMPLICATIONS: Copying of assessments and plans in the electronic medical records can potentially lead to erroneous documentation and fail to reflect changes in patient conditions. Further work is needed to determine the effect of copying on patient outcomes.
DISCLOSURE: Lokesh Venkateshaiah, No Financial Disclosure Information; No Product/Research Disclosure Information