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Related Experiment Videos

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

Wesley Winn1, Irshad A Shakir1, Heidi Israel1

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

Journal of Clinical Orthopaedics and Trauma
|April 1, 2017
PubMed
Summary

The widespread copy and paste function in electronic medical records (EMR) often leads to inaccurate patient documentation, particularly for high-risk injuries. This practice can obscure critical medical complications and treatment plans, impacting patient care.

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Area of Science:

  • Medical Informatics
  • Trauma Surgery
  • Healthcare Documentation

Background:

  • Electronic Medical Records (EMR) are standard, offering easy chart access but facilitating copy-paste functions.
  • The copy-paste feature in EMR may lead to inaccurate patient status representation.
  • High-risk injuries require precise documentation for effective management.

Purpose of the Study:

  • To evaluate the utilization of copy-paste functions in daily progress notes for patients with high-risk injuries.
  • To assess the accuracy of patient status documentation in EMRs.
  • To identify potential impacts of copy-paste practices on the reporting of complications and treatment plans.

Main Methods:

  • Retrospective review of patient charts at a Level 1 Trauma Center.
Keywords:
CopyCopy–pasteEMRElectronic medical recordOrthopedic surgeryPasteTrauma

Related Experiment Videos

  • Inclusion criteria: patients aged 18+ surgically treated for specific tibial fractures (bicondylar tibial plateau or open tibial shaft types I/II).
  • Manual comparison of daily subjective, objective, and plan note sections to identify copied content (coded as 1 for change, 0 for same).

    • Main Results:

    • An average of 85% of daily EMR data was copied across all notes.
    • Subjective (85-97%) and objective (71-92%) note sections showed high rates of copied content.
    • 30% of medical complications, 57% of injury-related complications, 56% of planned surgeries, 75% of unplanned surgeries, and 32% of discharge plans were inaccurately reported due to copy-paste practices.

    Conclusions:

    • Widespread use of the copy-paste function in EMRs leads to significant documentation inaccuracies.
    • There is a critical need to evaluate EMR charting practices and minimize copy-paste usage.
    • Implementing consistent note-writing guidelines and templates is essential to improve patient data accuracy and clinical picture clarity.