MMHA 6600 Week 2 Copy-Forward Note Review Example

New, Carried and True, or Carried and Stale: A Paragraph-Level Review of Copied-Forward Progress Notes on One Medical Unit

Student Name

Walden University

MMHA 6600: Healthcare Informatics and Technology Management

Instructor Name

Month Day, Year

New, Carried and True, or Carried and Stale: A Paragraph-Level Review of Copied-Forward Progress Notes on One Medical Unit

Purpose of the Review

Progress notes at Bramble Creek Hospital, the composite community hospital used in this course, are written in an electronic record that lets physicians and advanced practice providers copy the previous day's note forward and edit it. The feature saves time, and nobody proposes removing it. The question for this review is narrower: when a note is carried forward, what share of its content is still true on the day it is signed, and where does stale text collect?

The review sorts every paragraph of a sample of notes into three groups. A new paragraph was written or substantially rewritten that day. A carried-and-true paragraph was copied from an earlier note and still matched the patient on the signing date. A carried-and-stale paragraph was copied and no longer matched what the rest of the chart showed. The third group is the safety concern, because a reader cannot tell it apart from the second.

Why Copied Text Deserves a Review

Copying is now the main way inpatient notes are built. At one academic medical center, an analysis of millions of progress notes found that less than a fifth of the text had been typed by the author, with the rest copied from earlier notes or imported automatically from other parts of the record (Wang et al., 2017). The risks were described well before that study: errors carried from day to day, notes too long to read, and the loss of a clear record of the clinician's thinking (Hirschtick, 2006). A systematic review of copy-and-paste practices concluded that the feature is neither good nor bad in itself, and recommended that organizations monitor its use and make copied text identifiable (Tsou et al., 2017).

For a health administrator, the issue is partly clinical and partly legal. Notes that restate an examination never performed that day can support billing for work that was not done, and auditors increasingly ask how organizations govern copied text (Weis & Levy, 2014).

Sample and Method

Twenty inpatient stays of four days or longer on one medical unit were drawn from a single month. For each stay, the note from day three was compared paragraph by paragraph with the notes from days one and two and with the nursing flowsheets, laboratory results and medication administration record for day three. Two reviewers, a nurse informaticist and a hospitalist, sorted each paragraph independently and resolved disagreements together. The counts below are illustrative figures prepared for this sample paper, not a published audit.

Table 1

Paragraph Classification, Day-Three Progress Notes (Illustrative, 20 Stays)

One paragraph in five was carried and stale. Stale text was concentrated in the review of systems and the physical examination, the sections most often copied whole.

What the Stale Paragraphs Said

The stale paragraphs were not random. Seven examinations recorded clear lungs on a day when the nursing flowsheet documented new crackles and supplemental oxygen. Five results paragraphs restated a potassium value from admission that had since been corrected. Several plans still listed intravenous antibiotics after the switch to oral therapy the evening before. In three stays, a review of systems denied pain on a day when the patient had received two as-needed opioid doses.

None of these produced documented harm in the sample. Each, however, would mislead a covering clinician who read the note at night without opening the flowsheets, and each describes care that differs from the care given.

Where the Workflow Produces Stale Text

Three features of the current design explain the pattern. First, the note template copies the entire prior note by default, so the easiest path is to keep everything. Second, copied text looks identical to new text on screen and in print, so neither the author nor the reader can see which lines changed. Third, the examination and review of systems are written as narrative blocks rather than structured fields, so the author must remember to rewrite them; nothing prompts a fresh entry.

These are design choices, not personal failings. The same unit's physicians, asked informally, said they edit the assessment and plan carefully and skim the rest, which matches where the new paragraphs cluster in Table 1.

Recommendations

The review recommends four changes, in order of cost:

Each recommendation follows the review's own findings. Marking copied text makes the carried-and-stale category visible to the reader, which is the core recommendation of Tsou et al. (2017). Opening the examination blank means the section most often stale is written fresh each day.

Table 2

Recommendations, Owner and Effort

Visible marking and a narrower default address the two design features most responsible for stale text, while the quarterly review tells the committee whether the changes worked.

Limits

Twenty stays on one unit cannot represent the hospital. Reviewers judged truth against other parts of the chart, which may themselves be wrong. Paragraph counts treat a one-line edit and a full rewrite alike as new. The review looked at notes only, not at whether stale text changed any decision.

Conclusion

Copy-forward saves Bramble Creek's providers time, and most carried text is still true. One paragraph in five is not, and it hides in the sections clinicians copy whole. Marking copied text and narrowing what copies by default target that pattern directly, and a small quarterly review will show whether the share of stale paragraphs falls.

References

Hirschtick, R. E. (2006). Copy-and-paste. JAMA, 295(20), 2335-2336. https://doi.org/10.1001/jama.295.20.2335

Tsou, A. Y., Lehmann, C. U., Michel, J., Solomon, R., Possanza, L., & Gandhi, T. (2017). Safe practices for copy and paste in the EHR: Systematic review, recommendations, and novel model for health IT collaboration. Applied Clinical Informatics, 8(1), 12-34. https://doi.org/10.4338/ACI-2016-09-R-0150

Wang, M. D., Khanna, R., & Najafi, N. (2017). Characterizing the source of text in electronic health record progress notes. JAMA Internal Medicine, 177(8), 1212-1213. https://doi.org/10.1001/jamainternmed.2017.1548

Weis, J. M., & Levy, P. C. (2014). Copy, paste, and cloned notes in electronic health records: Prevalence, benefits, risks, and best practice recommendations. Chest, 145(3), 632-638. https://doi.org/10.1378/chest.13-0886