"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.
Copy-paste excess is a big bloater. On average, about a quarter of all notes contain content copied from elsewhere (other notes), with about a fifth of all note content duplicating other documentation. Understandable, since clinicians may think that, as with paper-based records, it is a service to use a progress note like a scrapbook, sparing the reader from having to flip through dense records.
Unfortunately, notes cluttered with copied-forward content make it unnecessarily difficult for the clinical reader to figure out what's new, trending or important. Connect Care documentation norms emphasize referencing prior documentation, in preference to copying into current documentation. The current note should highlight, not obfuscate, change.
There is a workflow that helps!
Progress notes can refer to prior notes (being specific about the note type, service and date; e.g., "see GIM Consult from 2021-09-20"). Even better is the ability to create an automated link to the prior documentation that will allow users to quickly see it in a popup window without losing context. The same trick works for referencing diagnostic imaging, laboratory result or other information found in Chart Review lists.