Physicians' Attitudes Towards Copy and Pasting in Electronic Note Writing

被引:83
作者
O'Donnell, Heather C. [1 ,2 ,3 ]
Kaushal, Rainu [2 ,4 ]
Barron, Yolanda [2 ]
Callahan, Mark A. [5 ]
Adelman, Ronald D. [6 ]
Siegler, Eugenia L. [6 ]
机构
[1] Childrens Hosp Montefiore, Albert Einstein Coll Med, Bronx, NY 10461 USA
[2] Weill Cornell Med Coll, Dept Publ Hlth, New York, NY USA
[3] Columbia Univ, Med Ctr, Dept Pediat, New York, NY USA
[4] Weill Cornell Med Coll, Dept Pediat, New York, NY USA
[5] FOJP Serv Corp, New York, NY USA
[6] Weill Cornell Med Coll, Dept Med, Div Geriatr & Gerontol, New York, NY USA
关键词
medical records system; computerized; documentation/mt [methods; attitude of health personnel; medical staff; hospital; user-computer interface; ORDER ENTRY; HEALTH-CARE; PATIENT-CARE; ERRORS; SYSTEM; FACULTY; RECORD;
D O I
10.1007/s11606-008-0843-2
中图分类号
R19 [保健组织与事业(卫生事业管理)];
学科分类号
摘要
The ability to copy and paste text within computerized physician documentation facilitates electronic note writing, but may affect the quality of physician notes and patient care. Little is known about physicians' collective experience with the copy and paste function (CPF). To determine physicians' CPF use, perceptions of its impact on notes and patient care, and opinions regarding its future use. Cross-sectional survey. Resident and faculty physicians within two affiliated academic medical centers currently using a computerized documentation system. Responses on a self-administered survey. A total of 315 (70%) of 451 eligible physicians responded to the survey. Of the 253 (80%) physicians who wrote inpatient notes electronically, 226 (90%) used CPF, and 177 (70%) used it almost always or most of the time when writing daily progress notes. While noting that inconsistencies (71%) and outdated information (71%) were more common in notes containing copy and pasted text, few physicians felt that CPF had a negative impact on patient documentation (19%) or led to mistakes in patient care (24%). The majority of physicians (80%) wanted to continue to use CPF. Although recognizing deficits in notes written using CPF, the majority of physicians used CPF to write notes and did not perceive an overall negative impact on physician documentation or patient care. Further studies of the effects of electronic note writing on the quality and safety of patient care are required.
引用
收藏
页码:63 / 68
页数:6
相关论文
共 27 条
[1]  
[Anonymous], 1999, To err is human: building a safer health system
[2]  
[Anonymous], 2008, Cochrane Database of Systematic Reviews, DOI DOI 10.1002/14651858.CD002894
[3]   Medication discrepancies in resident sign-outs and their potential to harm [J].
Arora, Vineet ;
Kao, Julia ;
Lovinger, David ;
Seiden, Samuel C. ;
Meltzer, David .
JOURNAL OF GENERAL INTERNAL MEDICINE, 2007, 22 (12) :1751-1755
[4]   Some unintended consequences of information technology in health care: The nature of patient care information system-related errors [J].
Ash, JS ;
Berg, M ;
Coiera, E .
JOURNAL OF THE AMERICAN MEDICAL INFORMATICS ASSOCIATION, 2004, 11 (02) :104-112
[5]   Computerized physician order entry: Helpful or harmful? [J].
Berger, RG ;
Kichak, JP .
JOURNAL OF THE AMERICAN MEDICAL INFORMATICS ASSOCIATION, 2004, 11 (02) :100-103
[6]  
Connolly Ceci, 2005, Washington Post, pA4
[7]   Impact of formal continuing medical education - Do conferences, workshops, rounds, and other traditional continuing education activities change physician behavior or health care outcomes? [J].
Davis, D ;
O'Brien, MAT ;
Freemantle, N ;
Wolf, FM ;
Mazmanian, P ;
Taylor-Vaisey, A .
JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION, 1999, 282 (09) :867-874
[8]   Impacts of computerized physician documentation in a teaching hospital: Perceptions of faculty and resident physicians [J].
Embi, PJ ;
Yackel, TR ;
Logan, JR ;
Bowen, JL ;
Cooney, TG ;
Gorman, PN .
JOURNAL OF THE AMERICAN MEDICAL INFORMATICS ASSOCIATION, 2004, 11 (04) :300-309
[9]  
Hammond Kenric W, 2003, AMIA Annu Symp Proc, P269
[10]   Unexpected increased mortality after implementation of a commercially sold computerized physician order entry system [J].
Han, YY ;
Carcillo, JA ;
Venkataraman, ST ;
Clark, RSB ;
Watson, RS ;
Nguyen, TC ;
Bayir, H ;
Orr, RA .
PEDIATRICS, 2005, 116 (06) :1506-1512