When it comes to inpatient coding, progress notes are one of the fundamental pieces of documentation that hospitals use to track a patient’s condition. As expected, these notes list any updates to the patient’s treatment or diagnosis, including any newly developed problems or complications. At first glance, it seems that updating these notes would be fairly straightforward and simple, but the fact of the matter isn’t always so easy.
According to a recent study, as much as 46 percent of the text in an average hospital progress note is copied and pasted from previous iterations. The analysis, which looked at over 23,000 records, also found that 36 percent of the text was imported, while only a minuscule 18 percent of each note was manually entered by the medical staff.
Even more surprisingly, the amount of cloned text versus new text varied quite a bit with the more experience a physician had. Residents had a new text rate of 11.8 percent, while direct care hospitalists entered new text at a rate of about 14.1 percent. The same rate in medical students, however, came in at 16.2 percent, meaning that the newest healthcare providers documented with the highest level of originality. Additionally, the study found that students wrote the longest progress notes with an average of 7,053 characters compared to the residents’ 6,720 and the hospitalists’ 5,006.
What does this mean for the medical world? Looking at the data, it appears that physicians are putting in less documentation effort the longer they work in a hospital. Though this may seem like an easy way to save time and keep the facility running, copying nearly half of the progress information can put a patient at risk for a multitude of errors when the copied text does not line up with their exact conditions. To avoid these potential problems, it is essential for all healthcare providers to submit full, original documentation with each patient in order to provide the best level of care.