"Note bloat" is a health record affliction that decreases the signal-to-noise ratio of clinical documentation and frustrates clinical decision-makers. As part of our documentation quality improvement initiative, we promote practical ways for clinicians to promote succinct, clear and actionable charting.
A common "bloater" is unnecessarily duplication of clinical documents. For example, a patient may be seen by a consultation service in the emergency department, where a consult note is completed. A decision is made to admit and the consult note includes relevant information that might otherwise be placed in an admitting history and physical (H&P) note.
Given a requirement that all inpatient encounters have an admitting H&P, the admitting service may be tempted to copy the consult note into a separate H&P note, or to place a comment in the H&P referencing the consult. However, both the Consult Note and the H&P are shared with external systems (e.g., Alberta Netcare), creating unhelpful duplication beyond Connect Care.
There is a workflow to avoid this!
An "Interval H&P" note can be created to point to a source document (e.g., Consult note) that takes the place of a H&P note. This avoids duplicate documentation while satisfying a documentation requirement.