Beyond Copy and Paste: Clinician Approaches to Meeting Information Needs During Note Writing

摘要

Clinicians need historical information that does not change over time, as well as other information from the notes of others to inform their documentation -to save time, they cut and paste since that is a feature in many conventional EHRs. Copy and paste is a solution to clinicians' needs that has associated downsides including errors. As part of a study of clinicians using an innovative system which gives them complete control over information selection and arrangement, two used the process of note splitting to meet needs that are sometimes solved through cut and paste; four others used text insertion (partial note sections) to address related needs. The purpose of this study is to enhance understanding of the note splitting and text insertion phenomena by describing the processes, the resulting creations, and the associated clinician rationales. Mixed methods included a thinkaloud protocol and analysis of user interface creations and time sequences.