Background: Time spent on electronic medical record (EMR) documentation is one of the top dissatisfiers for providers. With burnout at an all-time high, reducing provider burden while maintaining high quality care is essential to moving healthcare forward in a sustainable way. “While electronic documentation provides a number of benefits as compared to paper-based documentation, including improved legibility, real time accessibility, and decreased cost, it can be more cumbersome and time consuming for clinicians.” (1)(2). In addition, the potential for harm, whether deliberate or not, is high. “High-risk copy-and-paste errors, which are defined as mistakes with high potential risk for patient harm, fraud, or tort claim, have been reported in 10% of patient EMRs. (3)” Even without the harm, the percentage of an average progress note that is copied and pasted forward is usually above 50% leading to risky hand-offs between providers, unnecessary days of medications and treatments (steroids, antibiotics, telemetry), and increased insurance denials for documentation that is not significantly changed to reflect the need for hospitalization. With patients having access to their inpatient medical notes, there is an ever-present need to be vigilant for safe medical documentation practices to ensure the trust of our patients and eliminate patient confusion from erroneous documentation.
Purpose: Given the high chances of unsafe documentation from the current standards, a new type of document is needed that allows appropriate copy forward with a reduction in unsafe copying. The primary action of this quality improvement project was to create a progress note that would require a new daily assessment of the subjective and exam portions of the note while reminding the provider to adjust the assessment and plan portion. The primary outcome of this quality improvement project is to reduce the % copy forward of the subjective and exam portion of the note along with an overall goal of reducing copy forward.
Description: A new daily progress note piloted in August & September of 2021 at a community hospital. On day 1, the provider would complete the subjective, objective, assessment, and plan sections of the progress note template. On day 2, the progress note template would copy forward the assessment and plan with a prompt to edit this section while leaving the subjective and objective sections blank. Starting Oct 12, 2021, the new note template was formally introduced to the entire adult hospitalist group. Excluding other note types, the average patient encounters/day that would require a progress note was around 100 notes based on the pre-intervention data. Adoption of this new note template was rapid and reflected the majority of the provider encounters each day for our service line. The notes were monitored through an EMR report that provided the % copied from a prior note. The average percentage copy forward reduced from 34% to 15% over a 30-day period.
Conclusions: By utilizing a standardized note that improves the intended function of the copy and paste function within an EMR while alleviating the burden for documentation, providers can rely on a safer way to improve clinical documentation. Though % copy may not identify all the aspects of an appropriate high-quality note, % copy may provide the initial step to determine which provider is copying outside the group norm. This note shows the potential for improved clinical documentation over the current non-standardized EMR progress notes that also lacks an internal auditing process.
