2021-09-22

BBHR: Bloat Busters #04 - Link, Don't Copy

Building a Better Health Record (BBHR)
Bloat Busters #4 - Link, Don't Copy

Our Bloat Busters series can help clinicians prevent "note bloat", a digital health record affliction that decreases the signal-to-noise ratio of clinical documentation and frustrates clinical decision-makers. 

Connect Care users have not escaped a big "bloater" – copy-paste excess. 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, digital notes laden with copied-forward, then saved or edited, content make it unnecessarily difficult for the clinical reader to figure out what's new, current, trending or important. Connect Care documentation norms promote 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 context.

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