![]() Physicians spend 26% of their time on clinical documentation and 18% of their time writing on computers. Medical documentation has evolved with the rapid growth in the use of EHRs. In a previous study, we found that the adoption level of EHRs may be related to healthcare quality, with improved quality in the full-EHR stage compared with the no-EHR stage. The benefits of EHRs include improved access to records, the facilitation of communication, increased quality of patient-centered care through clinical decision support and safety engineering, cost savings, and improved data management for medical research and education. ![]() Physicians use EHRs to completely, succinctly, accurately and quickly document a patient's condition for their own use and their colleagues’ use. According to health provider surveys, EHR adoption can improve healthcare compared with paper-based medical records. The widespread adoption of EHRs has led to significant progress in the modernization of healthcare delivery. EHRs are different from other electronic files because they record the patient's condition and adjustments to treatment. Electronic health records (EHRs) are stored on a computer, and computer operating systems provide many convenient functions, such as copying and pasting, which can save time. Medical records refer to patient records that capture various conditions, examinations, differential diagnoses and treatment plans performed by medical providers engaged in medical services. Prospective research with cost analysis is needed. The discharge note completion rate initially decreased and not affected long term after restriction policy.Īppropriate policies to restrict the use of copying and pasting can lead to improvements in inpatient healthcare quality. The cross-correlation results showed a significant correlation between the prevalence of copied-and-pasted text and the 14-day readmission rate ( P < .001) and a relative risk of 1.105 ( P < .005), with a one-month lag. The prevalence of copying and pasting initially decreased, then increased, and then flatly decreased. ![]() Poisson regression was performed to identify the relative effect of the copy and paste restriction policy on the 14-day readmission rate or the discharge note completion rate within 3 days. The relationships between these factors were used cross-correlation to detect lag effect. 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 note completion. ![]() The prevalence of copying and pasting after the policy introduction was accessed by segmented regression for trend analysis. Copied-and-pasted text was detected in word templates using natural language programming with a threshold of 70%. We aimed to determine if the restricted use of copy and paste by doctors could improve inpatient healthcare quality.Ĭlinical documentation in an inpatient dataset compiled from 2016 to 2018 was used. The copy-and-paste feature is commonly used for clinical documentation, and a policy is needed to reduce overdocumentation. ![]()
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