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 its users easy access to vast amounts of patient data, together with tools for inserting chart data into notes. When used thoughtfully, these tools can save time when drawing attention to key information elsewhere in the chart. However, when not used carelessly, the same tools can make notes too lengthy and cumbersome to read, let alone discover what is most clinically important at a particular point in a patient's journey.
For example, inserting the last 48 hours of all inpatient lab results can add more than 50 lines of text to a note. Including only the results that are immediately relevant to changes in a patient's condition typically adds fewer than 10 lines of text to a progress note. Recognizing that all lab results are readily available to note readers, substituting a short interpretive statement about what has changed (e.g., "labs stable except for steady hemoglobin decline without reticulocytosis") adds as little as one line, but with more meaning than 50 lines.
Likewise, copying prior documentation to a new note may carry-forward inaccurate or irrelevant information while obscuring clinically relevant developments. These two documentation behaviours -- insertion of readily available chart data and copy-paste of prior documentation -- together drive much of what has become known as “note bloat”.
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”.