As we look toward our integrated EHR project, we continue to find ways to improve the EHR experience and outcomes. One common issue with EHRs is so-called “note bloat.” This is due to the automatic or inadvertent inclusion of extraneous information in clinician notes. A recent editorial discussed that the average note length in the US is up to 3.5 times as long as international notes (1). There is also evidence that clinicians spend most of their time looking at the assessment and plan part of the note (2).
Providers believe that inclusion of medication, lab, and radiology information via smart templates is necessary to support their coding level but this may not support good clinical documentation. Instead of including all of the labs, simply document the diagnosis and therapy in the assessment and plan. Instead of including all vitals, discuss the fever and tachycardia in the subjective. Instead of pulling in the entire chest x-ray report, note the findings of pneumonia in the assessment. Instead of saying “medications reviewed”, note in the plan that the antibiotics will be changed from ceftriaxone to amoxicillin. This type of documentation will support your billing and provide useful clinical information to your colleagues.
If information is present elsewhere in the EHR, then consider omitting it from your note. By reducing or removing all of the “bloat” that often gets added to the objective sections of the note, you can help improve communication, efficiency, and reduce burnout.
(1) Downing NL et al. Physician Burnout in the Electronic Health Record Era: Are We Ignoring the Real Cause? Ann Intern Med. 2018; 169(1):50-51
(2) Brown PJ et al. What do Physicians Read (and Ignore) in Electronic Progress Notes? Appl Clin Inform. 2014;5(2): 430-444