Change (Progress) Documentation
When documenting multiple times during an extended encounter, each “progress” record should emphasize what has changed since the prior note. Progress notes are about what is new; they are not meant to be understood in isolation from the rest of the chart.
Good change documentation is interpretive, rather than replicative. Pertinent change notes keep the chart lean, making it easier for other users to appreciate trends and developments.
Unhelpful change documentation degrades the signal-to-noise ratio of a shared health record. Clinical decision-making is hampered when important details are buried in unnecessary duplication and clutter.
Connect Care gives access to vast amounts of patient data, together with tools for inserting that data into notes. When used thoughtfully, data links can save time by drawing attention to key information found elsewhere in the chart. However, when used carelessly, these same tools can make notes lengthy and cumbersome to read, frustrating efforts to discover what is clinically important at a particular point in a patient's journey.
For example, replicating the last 48 hours of all inpatient lab results can add more than 50 lines to a note. By contrast, commenting on the clinical significance of a few key results rarely adds more than a few lines to a progress note. Powerful result review tools are available to all readers and can be used alongside notes when needed.
Another common contributor to note bloat is inappropriate copy-paste or copy-forward of material available elsewhere in the chart. Copying prior documentation to a new note may carry-forward inaccurate or irrelevant information while obscuring clinically relevant developments.
These two behaviours -- insertion of readily available chart data and copy-paste of prior documentation -- together drive much of what has become known as “note bloat”, a digital health record affliction that decreases the signal-to-noise ratio of clinical documentation.
Alberta Health Services and its Connect Care initiative have committed to a clinical documentation strategy that requires change documents to succinctly highlight what is changed, significant, abnormal, trending, exceptional or unexpected by comparison to the last summative or change note. Users are expected to ensure that change notes:
only include what is clinically significant;
are not redundant (replicating information easily reviewed elsewhere in the digital chart);
are not duplicative (replicating observations already recorded in prior change notes);
are organized in a way that brings the most important information to first attention (the top) and uses collapsible sections to expose additional details only should the reader require them;
use APSO sectioning (Assessment, Plan, Subjective [collapsible], Objective [collapsible]);
are formatted in a way that is easy to read;
emphasize text (e.g., abnormal results or observations) consistently; and
are efficient and digestible.
Where documentation by exception is appropriate, summarize lack of change with indicators like “no adverse change” or “within normal limits”.
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.