Duly noted: Lessons from a two-site intervention to assess and improve the quality of clinical documentation in the electronic health record

Fanucchi, Laura; Yan, Donglin; Conigliaro, Rosemarie L.

doi:10.4338/aci-2016-02-cr-0025

Cited by 12 publications

(17 citation statements)

References 13 publications

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“…However, in contrast to our study, it did not lead to any improvement in clinical documentation based on Physician Documentation Quality Instrument-9 [15].…”

Section: Discussioncontrasting

confidence: 99%

“…A recently published prospective quality improvement project used either a lecture or a lecture and individual feedback on progress note as an intervention in two internal medicine residency programs [15]. However, in contrast to our study, it did not lead to any improvement in clinical documentation based on Physician Documentation Quality Instrument-9 [15].…”

Section: Discussioncontrasting

confidence: 87%

“…To date, scant attention has been paid to intervene, aiming to reduce such a practice. A recent study using a lecture and individual feedback on progress notes as an intervention to improve clinical documentation did not find improvement in clinical documentation [15].…”

Section: Introductionmentioning

confidence: 91%

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Use of dictation as a tool to decrease documentation errors in electronic health records

Hadidi

Upadhaya

Shastri

et al. 2017

Journal of Community Hospital Internal Medicine Perspectives

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Background: Use of Electronic Health Records is increasing. Copy-and-paste function is frequently used with higher rates of documentation errors. Studies to determine the nature of such errors are needed.Objectives: Determination of the effect of implementing a dictation system for completing notes on the quality of clinical documentation. We hypothesized that implementation of the dictation system for note writing would decrease the rate of errors in the progress notes as well as decrease the rate of copying and pasting. Design/Methods: A prospective interventional study in inpatient medical service for six months’ duration starting in July 2016. Resident physicians’ charts were reviewed by the attending physician on a daily basis. This study was done in a community based hospital affiliated to a university program. Residents’ physicians included Internal Medicine, Transitional year and Combined Internal Medicine Pediatrics residents. Charts reviewed for hospitalized patients. A total of 54 residents were offered a pre-intervention survey indicating their subjective use of copy/paste function. Response rate of 85.18%. Progress notes were reviewed on a daily basis for residents on their inpatient rotation. A total of 621 notes were reviewed. Results: Percentage of notes copied prior to the intervention was 92.73% which decreased to 49.71% post-intervention (RR of 0.54, 95% CI 0.48 0.60 Z statistic 11.005 with p-value <0.0001). Of the copied notes percentage of errors pre-intervention was 58% with no errors identified post-intervention (RR of 0.005, 95% CI 0.0003 0.0795 Z statistic 3.752 with p-value 0.0002). Most of the errors are from notes copied by the same author (85.8%). The most common documentation error was in the physical examination section. Conclusion: Implementing a dictation system eliminated documentation errors over our six months’ study. Further studies are needed to check long effects of using such systems on documentation errors

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“…However, in contrast to our study, it did not lead to any improvement in clinical documentation based on Physician Documentation Quality Instrument-9 [15].…”

Section: Discussioncontrasting

confidence: 99%

Section: Discussioncontrasting

confidence: 87%

See 1 more Smart Citation

Use of dictation as a tool to decrease documentation errors in electronic health records

Hadidi

Upadhaya

Shastri

et al. 2017

Journal of Community Hospital Internal Medicine Perspectives

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“…Of the 23 included articles, 11 used comments, 21,22,[27][28][29][30][31][32]34,36,38 9 used a rubric, [17][18][19][20][21][22][35][36][37] 6 used a checklist, [23][24][25][26]36,38 2 used traditional grading scales, 22,27 and 3 tested novel feedback systems. 30,33,39 Checklists and rubrics can provide clear, objective feedback and often do not require prior knowledge of the patient or assignment. 25 These feedback tools provide a structural framework that offers greater consistency among graders and allow for improved grading for less experienced graders.…”

Section: Reviewmentioning

confidence: 99%

How Do Learners Receive Feedback on Note Writing? A Scoping Review

Hansen,

Klute,

Yadav

et al. 2024

Acad Med

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Purpose The literature assessing the process of note-writing based on gathered information is scant. This scoping review investigates methods of providing feedback on learners’ note-writing abilities. Method Scopus and Web of Science were searched for studies that investigated feedback on student notes or reviewed notes written on an information or data-gathering activity in health care and other fields in August 2022. Of 426 articles screened, 23 met the inclusion criteria. Data were extracted on the article title, publication year, study location, study aim, study design, number of participants, participant demographics, level of education, type of note written, field of study, form of feedback given, source of the feedback, and student or participant rating of feedback method from the included articles. Then possible themes were identified and a final consensus-based thematic analysis was performed. Results Themes identified in the 23 included articles were as follows: (1) learners found faculty and peer feedback beneficial; (2) direct written comments and evaluation tools, such as rubrics or checklists, were the most common feedback methods; (3) reports on notes in real clinical settings were limited (simulated clinical scenarios in preclinical curriculum were the most studied); (4) feedback providers and recipients benefit from having prior training on providing and receiving feedback; (5) sequential or iterative feedback was beneficial for learners but can be time intensive for faculty and confounded by maturation effects; and (6) use of technology and validated assessment tools facilitate the feedback process through ease of communication and improved organization. Conclusions The various factors influencing impact and perception of feedback include the source, structure, setting, use of technology, and amount of feedback provided. As the utility of note-writing in health care expands, studies are needed to clarify the value of note feedback in learning and the role of innovative technologies in facilitating note feedback.

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“…However, only a few institutes use these tools to educate physicians to improve their documentation quality. More published data is available about initiatives on documentation improvement addressing the copypasting function [21][22][23]. To ensure that copy-pasting is used appropriately and that patient safety is not compromised, it is essential to supervise its use and give feedback to our trainees and fellows when it is being misused.…”

Section: Consmentioning

confidence: 99%

Copy-Pasting in Patients’ Electronic Medical Records (EMRs): Use Judiciously and With Caution

Al Bahrani,

Medhi

2023

Cureus

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An electronic medical record (EMR) is an electronic, comprehensive, and up-to-date compilation of a patient's medical history and information stored in a secure digital format. It provides real-time access to patient data, enabling healthcare providers to make informed decisions quickly and accurately. EMR systems streamline a patient's healthcare journey and enable shared care across the medical practice. By providing a comprehensive view of a patient's medical history, EMRs can be invaluable tools for physicians and healthcare providers, allowing them to collaborate more effectively and provide better care. Additionally, EMRs can help reduce paperwork, improve accuracy, and increase efficiency, ultimately leading to improved patient outcomes. The true potential of EMR systems can be realized when they are used in conjunction with evidence-based medicine methodologies, quality improvement initiatives, and team-based care. This combination of technologies and practices can revolutionize healthcare delivery, improving patient outcomes, greater efficiency, and cost savings."Copy-pasting" is an essential feature of EMR systems, with physicians relying on it for up to 35.7% of their workflow. By leveraging the copy-pasting feature of their EMR system, physicians can ensure that their data capture is accurate and timely, leading to better patient care. Copy-pasting can be a valuable tool for physicians, saving time and allowing them to focus on practical clinical issues. However, it is essential to note that while most clinicians copy-paste, 25% of them believe it can lead to a high frequency of medical errors, with the potential for a significant number of errors being attributed to this practice. Therefore, physicians must exercise caution when copy-pasting and take the necessary steps to ensure accuracy and reduce the risk of errors.Copy-pasting can cause severe adverse patient events by introducing new inaccuracies, rapidly spreading inaccurate or outdated information, leading to discordant notes, and creating long notes that mask essential clinical information. Despite these risks, copy-pasting has become widely used in EMRs. Additionally, copypasting can reduce the time spent on documentation, allowing healthcare providers to focus more on patient care. Inappropriate copy-pasting can have serious consequences, such as compromising data integrity, endangering patient safety, increasing costs, and even leading to fraudulent malpractice claims.In conclusion, copy-pasting can be helpful for healthcare professionals, but it must be used cautiously. Proper education and safeguards should be implemented to ensure accuracy and up-to-date patient data. Additionally, healthcare professionals should be aware of the legal implications of copy-pasting, as it may be considered a form of medical malpractice. With the proper precautions, copy-pasting can be a safe and efficient way to save time and reduce errors in patient records.

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Duly noted: Lessons from a two-site intervention to assess and improve the quality of clinical documentation in the electronic health record

Cited by 12 publications

References 13 publications

Use of dictation as a tool to decrease documentation errors in electronic health records

Use of dictation as a tool to decrease documentation errors in electronic health records

How Do Learners Receive Feedback on Note Writing? A Scoping Review

Copy-Pasting in Patients’ Electronic Medical Records (EMRs): Use Judiciously and With Caution

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