Physicians work tirelessly trying to provide their patients with the best possible care. The physical exam is just the start. Keeping up with patient history and taking care to enter accurate updates to the patient record can be critical for patient health. That is why "Note Bloat" has become such a problem today.
Note Bloat has become overwhelming for many reasons.
--For times sake, many physicians have resorted to copying and pasting recommendations on one patient's issue to a patient with the same diagnosis and miss information that is only pertinent to the first patient - such as an allergy to a medication.
--A doctor makes a mistake pertaining to left or right side of the body and a second doctor copies that information into their note. When the first doctor corrects the original note, the second is still left incorrect.
--Doctors may copy information from a previous note and make revisions but leave information in the note that is no longer accurate, like a fever, rash, etc.
These types of mistakes can lead to violations of patient confidentiality and HIPPA rules, lead to malpractice suits, and most importantly negatively affect patient care.
Here are three ways to fight Note Bloat:
- Stop copying and pasting information. Speaking is much faster than typing, so speak the patient's information into the note. This provides you a custom record for each visit and the peace of mind your patient's documentation is accurate.
- Dictate your note in front of the patient. This will reinforce your observations and allow for correction if needed.
- Review your note for accuracy. Physicians are accountable for their documentation, this allows you to take control of your work and sign it with confidence.
Don't let Note Bloat continue in your EHR, it is a practice that eventually, one way or another, must be corrected.