Copy-and-Paste in Medical Student Notes: Extent, Temporal Trends, and Relationship to Scholastic Performance

Abstract

Background Medical students may observe and subsequently perpetuate redundancy in clinical documentation, but the degree of redundancy in student notes and whether there is an association with scholastic performance are unknown. Objectives This study sought to quantify redundancy, defined generally as the proportion of similar text between two strings, in medical student notes and evaluate the relationship between note redundancy and objective indicators of student performance. Methods Notes generated by medical students rotating through their medicine clerkship during a single academic year at our institution were analyzed. A student–patient interaction (SPI) was defined as a history and physical and at least two contiguous progress notes authored by the same student during a single patient's hospitalization. For some students, SPI pairs were available from early and late in the clerkship. Redundancy between analogous sections of consecutive notes was calculated on a 0 to 100% scale and was derived from edit distance, the number of changes needed to transform one text string into another. Indicators of student performance included United States Medical Licensing Exam (USMLE) scores. Results Ninety-four single SPIs and 58 SPI pairs were analyzed. Redundancy in the assessment/plan section was high (40%) and increased within individual SPIs (to 60%; p < 0.001) and between SPI pairs over the course of the clerkship (by 30–40%; p < 0.001). Students in the lowest tertile of USMLE step II clinical knowledge scores had higher redundancy in the assessment/plan section than their classmates (67 ± 24% vs. 38 ± 22%; p = 0.002). Conclusion During the medicine clerkship, the assessment/plan section of medical student notes became more redundant over a patient's hospital course and as students gained clinical experience. These trends may be indicative of deficiencies in clinical knowledge or reasoning, as evidenced by performance on some standardized evaluations.

Improved Medical Student Engagement with EHR Documentation following the 2018 Centers for Medicare and Medicaid Billing Changes

“…This is likely multifactorial, but literature suggests that students may be less discerning in their note content and may have more redundancy and copy-pasted information. 15 Students also spent more time editing notes; most likely secondary to a lower proficiency compared with their resident and attending colleagues. This highlights the importance of adequate EHR training for medical students, in addition to education on note format and content.…”

“…20 Further work to develop enhanced evaluation methods of medical student notes may provide insight into medical student clinical knowledge and reasoning. 15 Further evaluation should also focus on the effects of these changes on attending documentation burden and quality of documentation to ensure that the desired outcomes are being achieved without introducing new unintended consequences.…”

An Exploratory Study of Allied Health Students' Experiences of Electronic Medical Records During Placements

“…A large number of studies have shown that health care providers often work around eMRs or use eMRs in sub-optimal ways, to avoid extra steps, slow processes, or systems. [33][34][35] Exposure to these suboptimal workflows are likely to result in students learning and adopting these unintended ways of working in their own practice, 36 which may adversely impact the delivery of safe patient care. Formal training and the availability of ongoing eMR support from recognized system trainers or super-users would ensure "correct" habits are formed in the early stages of a student's eMR journey.…”

Restricted use of copy and paste in electronic health records potentially improves healthcare quality

“…One study showed a negative relationship between medical student performance and longer documentation. [19] We hypothesize that advanced restrictions on the use of the copy-and-paste function have the potential to affect inpatient healthcare quality and influence timely note completion. Physicians may overrely on the copy-and-paste function to meet timeline goals, and they must perform clear history taking and physical examinations with accurate adjustments and optimal treatments.…”

“…Longer notes could lead to reader fatigue. One study showed a negative relationship between medical student performance and longer documentation [19] …”