BBHR: Bloat Busters #05 - Interpretation >> Replication

Building a Better Health Record (BBHR)
Bloat Busters #5 - Interpretation Over Replication

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. 

The clinical value of progress (non-summative) documentation relates to a ratio of signal (clinically important new information reflecting developments in a patient's experience) to noise (information related to the patient, but not directly relevant to clinical progress) multiplied by interpretation (application of clinical expertise to information to advance understanding and support decision-making):

Digital health records make it easy to amplify noise in progress documentation. Copy-paste of prior documentation and some text automations ("SmartStuff") pull data blocks (e.g., vitals and laboratory flowsheets) into a note, adding signal, but often in company of a lot of noise. Authors can be lulled into thinking that documentation is done, while the note remains lean on clinically helpful interpretationThe reader of a progress note needs to know clearly what the writer thought and did for patient care.

The Connect Care Documentation Quality Improvement initiative ("Building a Better Health Record") introduces a number of new text automations, templates and other documentation aids that can help authors replicate chart data more selectively, while also being explicit about the clinical meaning of observations. Continue to follow this thread as we describe how to use the tools to your advantage.

No comments:

Post a Comment

Please feel free to contribute to discussion by posting comments here. For general suggestions, please use the link in the column to the right.