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The Clinical Documentation Process Has Become Longer, More Repetitive, and Less Informative

A recent study conducted at Oregon Health & Science University, a large academic medical center, seems to confirm this observation. They compared almost 3 million outpatient progress notes across 46 specialties and found that note length increased 60.1 percent in less than a decade, from a median of 401 words in 2009 to 642 words in 2018. Median note redundancy, a function of copying and pasting and templating, increased 10.9 percent, from 47.9 to 58.8 percent, over that same period of time. It was found that residents and fellows also wrote significantly longer notes than more experienced clinicians.


The result of this is “note bloat.” Indeed, this issue is not confined to the outpatient setting. I was recently reviewing an inpatient medical record of a four-day stay for a project, and it consisted of 855 pages. There were literally hundreds of pages of templated nurses’ notes, vital sign flow charts, and unending laboratory result readouts, interspersed with highly templated and minimally informational provider notes. Locating the emergency department note and the admitting H&P was like finding a needle in a haystack of needles. Sometimes it is nearly impossible to ferret out the story of the encounter.


The outpatient study found that median note length increased across all specialties, with an increase of 84.1 percent for adult specialties and 57.8 percent in pediatric services. By 2017-2018, the majority of the note was templated, with 55.9 percent templated, 14.7 percent copied, and just 29.4 percent of text being directly typed. Note that redundancy increased across all specialties and subgroups, but the worst offenders were the surgical specialties, which increased by 16.6 percent, and adult specialties, which crept up by 12.8 percent. In 2018, a total of 38 of the 46 studied specialties exceeded a median note redundancy of 50 percent. This means that more of the note was identical to the previous note than was newly crafted with novel information.


Long and repetitive notes make it harder to care for patients. Critical information can be lost in the white noise. Generation of documentation through templating and copying and pasting can insert or propagate inaccurate or outdated information. Reader satisfaction is decreased, and medical decision-making is hindered by these behaviors.


This study suggests that introducing a standardized note template and educating residents about documentation best practices improves the quality of the notes generated. They referenced other studies that recommended electronic solutions to decrease redundant importation of large data fields and design text prompts to encourage novel documentation.

Some electronic medical records have the functionality to be able to distinguish all copied and pasted material.


The impression in the study was that the impetus for much of this note bloat was related to billing. The evaluation and management (E&M) requirements for office visits changed on Jan. 1, 2021. Medical decision-making or time are now the basis for billing. Someone should reprise this study to see if the change in billing requirements affected how notes are composed.


Original story was posted on November 30, 2021 by Erica E. Remer, MD, CCDS

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