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 progress 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.

Note Bloat

Connect Care contains vast amounts of patient data, together with powerful tools for inserting that data into notes. When used thoughtfully, data links can save time by drawing attention to information found elsewhere in the chart. However, when used carelessly, these same "Smart" tools can make notes difficult 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 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. Result review tools are available and can be used alongside notes when needed by readers.

Inappropriate copy-paste or copy-forward of material available elsewhere in the chart may carry-forward inaccurate or irrelevant information while further cluttering notes and 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.

Good documentation habits can reduce note bloat while increasing the clinical value of the digital health record:

• Byte: Bloat Busters - Where's the Bloat?

• Byte: Bloat Busters - Interpret, Don't Replicate

• Byte: Bloat Busters - Use Interval H&P Notes

• Byte: Bloat Busters - Expose Note Sources

• Byte: Bloat Busters - Link, Don't copy

• Blog: Bloat Busters - Avoid Superfluous Data

Note Focus

Alberta Health Services' clinical documentation strategy promotes change documents that succinctly highlight what is changed, significant, abnormal, trending, exceptional or unexpected by comparison to the last summative 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 over tables (e.g., abnormal results or observations) consistently; and

• are efficient and digestible.

Where documentation by exception is appropriate, indicate lack of change with indicators like “no adverse change” or “within normal limits”.

Note Links

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.

• Byte: Bloat Busters - Link, Don't copy

• Tip: Using Active Document Links

Note Templates

Basic and advanced progress note templates are available to users, with simple SideBar links that open the best editor to the best template with just one click. These templates adhere to provincial standards for progress note formatting. They make use of chart links and data insertions that are prescriber-friendly, prose-ready and standards-compliant (e.g., medication sig and date formats). The basic variants work for most workflows and can automatically adjust themselves to the provider's specialty and patient's problems. The advanced templates work best for users who have adopted problem oriented charting.

• Use "core progress" as search terms to find basic progress note SmartText templates, or

• Use "poc progress" (".pocprogress") as search terms to find advanced progress note SmartText or SmartPhrase templates.

More Information

• Norms: Documentation

• Bytes: Bloat Busters