Only 18 percent of electronic inpatient progress notes are original entries by clinicians, according to a research letter in JAMA Internal Medicine.
Three UC San Francisco physicians — Michael D. Wang, MD, Raman Khanna, MD, and Nader Najafi, MD — analyzed 23,630 inpatient progress notes from an eight-month period in 2016. An Epic EHR system stored the notes, which were written by 460 clinicians including direct care hospitalists, residents and medical students at UCSF Medical Center.
The researchers used an EHR tool to identify the source of each character in a signed note. The tool logged which characters were entered manually, imported from another source or copy-and-pasted from a previous note.
Eighteen percent of the text in a typical note was manually entered, while 36 percent was imported and 46 percent was copied. Residents (51.4 percent) tended to copy more than medical students (49 percent) or direct care hospitalists (47.9 percent).
"Although we conducted a single-center, single-service analysis, we observed patterns that were consistent with what has been measured in previous studies and what clinicians have observed anecdotally," the study authors wrote.