SHM Converge Scientific Abstract ePoster Gallery-Reducing Copy and Paste in Progress Notes

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This poster describes a quality improvement project at Johns Hopkins–Howard County General Hospital aimed at reducing unsafe copy-and-paste behavior in electronic medical record (EMR) progress notes. The problem addressed is that documentation takes significant provider time, but excessive copying can create patient safety risks, poor handoffs, unnecessary continuation of treatments, and insurance denials.<br /><br />To improve documentation, the team designed a standardized daily progress note for follow-up encounters. On day 1, providers complete the subjective, objective, assessment, and plan sections. On day 2, the template automatically copies forward only the assessment and plan, while prompting the provider to edit those sections; the subjective and objective sections remain blank to encourage fresh documentation. An EMR-generated report was used to measure the percentage of note content copied.<br /><br />The intervention was piloted over several weeks, and adoption was rapid, covering most provider encounters each day. The primary outcome was a significant reduction in copy-forward behavior within 30 days. Average copied content dropped from 34% to 21%, and median copied content fell from 28% to 15%.<br /><br />The authors conclude that a standardized note can preserve the useful aspects of copy-forward while reducing unsafe duplication and documentation burden. They also note that EMR copy percentages may help identify providers or services that are copying excessively. A limitation of the project is that it was conducted at a single site.

Asset Subtitle

Trushar M. Dungarani

Meta Tag

Author List Anirudh Sridharan, Trushar M. Dungarani

Category Innovations

Concept Hospital EMR

Concept Progress Note

Concept Copy and Paste

Concept Copy Forward

Concept Patient Safety

Distinguished Non-Finalist

Presenter Organization Johns Hopkins Medicine

Presenting Author Trushar M. Dungarani

Track Technology in Hospital Medicine

Keywords

electronic medical record

copy-and-paste

progress notes

quality improvement

patient safety

documentation burden

standardized note template

copy-forward behavior

assessment and plan

Johns Hopkins

Hospital EMR

Progress Note

Copy and Paste

Copy Forward

Patient Safety