2021-09-15

BBHR: Bloat Busters #01 - Using Interval H&P Notes

Building a Better Health Record (BBHR)
Bloat Busters #1 - Using Interval H&P Notes

"Note bloat" is a digital 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 will share practical ways for clinicians to benefit from Connect Care documentation norms that promote succinct, clear and actionable charting.

A common "bloater" is unnecessarily duplication of clinical documents. A patient may be seen by a consultation service in the emergency department, where a consult note is completed and a decision is made to admit to an inpatient facility. The consult may have anticipated admission and included all information that might otherwise be placed in an admitting history and physical (H&P). 

Given the requirement that all inpatient encounters have an admitting H&P, the admitting service may be tempted to copy the consult into a separate H&P, 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) and so extend unhelpful duplication beyond Connect Care.

There is a workflow to avoid this! An "Interval H&P" note can be created to point to the source document (e.g., Consult Note), avoid copy-paste and also avoid duplicate shares with external systems.

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