The Clinical Documentation Process has Become Longer, More Repetitive, and Less Informative

The concern of “note bloat” is gaining traction.

Is it your perception that clinical notes have grown longer, and yet less informative?

A recent study conducted at Oregon Health & Science University, a large academic medical center, seems to confirm this observation. They compared almost 3 million outpatient progress notes across 46 specialties, and found that note length increased 60.1 percent in less than a decade, from a median of 401 words in 2009 to 642 words in 2018. Median note redundancy, a function of copying and pasting and templating, increased 10.9 percent, from 47.9 to 58.8 percent, over that same period of time. It was found that residents and fellows also wrote significantly longer notes than more experienced clinicians.

The result of this is “note bloat.” Indeed, this issue is not confined to the outpatient setting. I was recently reviewing an inpatient medical record of a four-day stay for a project, and it consisted of 855 pages. There were literally hundreds of pages of templated nurses’ notes, vital sign flow charts, and unending laboratory result readouts, interspersed with highly templated and minimally informational provider notes. Locating the emergency department note and the admitting H&P was like finding a needle in a haystack of needles. Sometimes it is nearly impossible to ferret out the story of the encounter.

The outpatient study found that median note length increased across all specialties, with an increase of 84.1 percent for adult specialties and 57.8 percent in pediatric services. By 2017-2018, the majority of the note was templated, with 55.9 percent templated, 14.7 percent copied, and just 29.4 percent of text being directly typed. Note that redundancy increased across all specialties and subgroups, but the worst offenders were the surgical specialties, which increased by 16.6 percent, and adult specialties, which crept up by 12.8 percent. In 2018, a total of 38 of the 46 studied specialties exceeded a median note redundancy of 50 percent. This means that more of the note was identical to the previous note than was newly crafted with novel information.

Long and repetitive notes make it harder to care for patients. Critical information can be lost in the white noise. Generation of documentation through templating and copying and pasting can insert or propagate inaccurate or outdated information. Reader satisfaction is decreased and medical decision-making is hindered by these behaviors.

I once had a coder approach me with concern. She had found insertion of an operative note in a record she was coding, and each subsequent day was labeled as “post-op day x+1.” The issue was, on further investigation, the surgery had actually been performed on the previous visit. Had the coder not been so attentive, this patient might have undergone two prostatectomies in two months. This is not just bothersome; this would have been fraud, had it been improperly coded and billed.

When I am teaching, I do an exercise with providers. I ask them to raise their hands if they love the convenience of copying and pasting. They sheepishly all do so. I then ask them to raise their hands again if they love reading other peoples’ copied and pasted notes. They do not.

This study suggests that introducing a standardized note template and educating residents about documentation best practices improves the quality of the notes generated. They referenced other studies that recommended electronic solutions to decrease redundant importation of large data fields and design text prompts to encourage novel documentation.

Some electronic medical records have the functionality to be able to distinguish all copied and pasted material. A system I worked in grayed out all text identical to the previous note, with the ability to identify novel documentation. It was sometimes shocking at how few words differed from day to day.

The impression in the study was that the impetus for much of this note bloat was related to billing. The evaluation and management (E&M) requirements for office visits changed on Jan. 1, 2021. Medical decision-making or time are now the basis for billing. Someone should reprise this study to see if the change in billing requirements affected how notes are composed.

I strongly concur with the recommendation that facilities that have trainees and orientees should implement a documentation curriculum. My curriculum is set up as Best Documentation Practices: The Good, The Bad, and The Risky; Documentation for Quality and Reimbursement; and Clinical Documentation Integrity. If any of your institutions are interested in accessing my provider modules with CME, have them check out www.icd10md.com.

For single purchases, they can use the discount code icduniv20 – or for bulk purchases, they can contact me for institutional pricing. I’d also be happy to do virtual training. Anything to get “mentation” back into documentation.

Programming Note: Listen to Dr. Erica Remer when she co-hosts Talk Ten Tuesdays with Chuck Buck, Tuesdays at 10 Eastern.