Restricted use of copy and paste in electronic health records potentially improves healthcare quality.

ABSTRACT:

Abstract

The copy-and-paste feature is commonly used for clinical documentation, and a policy is needed to reduce overdocumentation. We aimed to determine if the restricted use of copy and paste by doctors could improve inpatient healthcare quality.Clinical documentation in an inpatient dataset compiled from 2016 to 2018 was used. Copied-and-pasted text was detected in word templates using natural language programming with a threshold of 70%. The prevalence of copying and pasting after the policy introduction was accessed by segmented regression for trend analysis. The rate of readmission for the same disease within 14 days was assessed to evaluate inpatient healthcare quality, and the completion of discharge summary notes within 3 days was assessed to determine the timeliness of n

SUBMITTER: Cheng CG 

PROVIDER: S-EPMC8797538 | biostudies-literature | 2022 Jan

REPOSITORIES: biostudies-literature