The traditional goal of progress notes is to provide a concise, up-to-date reflection of the patient’s condition and the clinician’s thought process.1 Electronic health records (EHRs) allow physicians writing these notes to supplement traditional manual data entry with copied or imported text. However, copying or importing text increases the risk of including outdated, inaccurate, or unnecessary information, which can undermine the utility of notes and lead to a clinical error.2 Previous studies quantifying copied text were limited by available tools, which could not distinguish manually modified text from automatically updated imported values in electronic note templates.3 We used a new EHR tool that distinguishes manual, imported, and copied text in hospital progress notes with character-by-character granularity to describe documentation practices by medical students, residents, and direct care hospitalists.
Wang MD, Khanna R, Najafi N. Characterizing the Source of Text in Electronic Health Record Progress Notes. JAMA Intern Med. Published online May 30, 2017. doi:10.1001/jamainternmed.2017.1548