A Practical Approach for Monitoring the Use of Copy-Paste in Clinical Notes.

The use of copy-paste in authoring clinical notes has been widely embraced by busy providers, but inappropriate copy-paste has been lambasted by critics for introducing risks related to patient safety and regulatory compliance. At an integrated academic health system with over 4,100 providers writing notes, we developed a pragmatic approach to assess the use of copy-paste. From January 1-December 31, 2020, approximately 2.3M inpatient notes and 6.6M ambulatory clinic notes were authored in our electronic health record. Of the inpatient notes, 42% used copy-paste, and 19% of overall note content was copied; in ambulatory notes, 18% used copy-paste and 12% of note content was copied. We describe an approach for including providers' copy-paste usage statistics into the ongoing professional practice evaluation process required for hospital accreditation, thereby offering individual training opportunities related to the lack of use of copy-paste or its potential overuse. ©2021 AMIA - All rights reserved.