Digital Documentation: More or Less?
One note
When Dr. Weed proposed the problem-oriented medical record, typical notes consisted of only a few sentences with little structure that meant nothing to anyone other than the note’s author. At that time, more documentation meant better-informed caregivers across the clinical spectrum. With the advent of EMRs, the explosion of notes creates an environment where there is too much documentation rather than too little. As the time available to focus on each patient diminishes, clinicians similarly have less and less time to review all the notes about a patient’s current condition. Therefore, they choose some information to review and dismiss the rest, potentially overlooking critical patient information.
To effectively use EMRs to manage patient care, organizations must decrease the volume of documentation by embracing processes and policies that reduce redundant information. Unlike a final philosophy exam in college, shorter prose jam packed with critical facts delivers more value than drawn out descriptors that offer limited value in patient care.
Informaticists do not currently know what works best to decrease the size of notes. However, they do know that excessive documentation leads to bloated records and obscuration of important patient information. Potential solutions to reducing the bloat require close evaluation.
Removal of the cut-and-paste function within EMRs offers one option. Streamlined structured templates in lieu of free text notes offers another.
A third solution, the unified clinical note, is more radical but deserves serious consideration. The unified note requires all clinicians to write their notes in the same place within an EMR. This format creates a narrative that becomes an ongoing, longitudinal description of the patient’s condition, the clinicians’ assessment of the patient, and the current care plan.
The unified note ensures all caregivers see the same information, reduces duplicative data entry, and lessens everyone’s documentation burden.
The positive impact of patient-centered medical homes and specialized, procedure-focused surgical teams illustrates that modern medicine requires a diverse clinical team approach to deliver care that is both high-quality and efficient. Perhaps we need a similar approach to apply those adjectives to the documentation process.
Barry Chaiken is the president of DocsNetwork Ltd. and has more than 25 years of experience in medical research, epidemiology, clinical information technology, and patient safety. He is board certified in general preventive medicine and public health and is a fellow and former board member and chair of HIMSS. At DocsNetwork, Chaiken worked on quality improvement studies, health IT clinical transformation projects, and clinical investigations for the National Institutes of Health, UK National Health Service, and Boston University Medical School. He is currently an adjunct professor of informatics at Boston University’s School of Management. Chaiken may be contacted at bchaiken@docsnetwork.com.
References
Blaise Pascal. (2016, January 27). In Wikiquote. Retrieved from https://en.wikiquote.org/w/index.php?title=Blaise_Pascal&diff=2075448&oldid=2075378
SOAP note. (2016, August 9). In Wikipedia, the Free Encyclopedia. Retrieved from https://en.wikipedia.org/w/index.php?title=SOAP_note&diff=733683688&oldid=732416684