[epicproviders] Epigram: Spring Cleaning

[Epic - All Provider Staff]

Epigram: Spring Cleaning


With the weather warming, it is a great time to do some spring cleaning! Over the next few weeks, focus on streamlining notes and reducing “note bloat”. Improved notes are faster to create, more efficient to read and can save you from risk by reducing information that you have not fully addressed.



What is note bloat

Note bloat is the addition of extraneous information into notes that is addressed elsewhere in the chart and does not directly relate to the current (today) visit or inpatient day. Extraneous material makes it harder to read notes- notes are longer and the reader needs to evaluate each data point to wonder if it is relevant and why it is mentioned. Materials like labs that are not related to the patient’s condition and are normal, repeating material from old notes, copying multiple scan results and other material are simply not needed.



The EMR is the medical record. It does not need to be recreated in your notes.



What should be in a note

The material that should be in a note is that material that references why you saw the patient today including a medically appropriate history and exam, what you found and evaluations of material data points with a plan in support of your medical decision making.



You can reduce note bloat with the aid of many personalization tools in Epic. Reach out to me or the training team (4-epic) to learn how.



Examples

  *   Lab studies: abnormal results (or studies you are trending for a patient problem) should be addressed. Other normal labs from the visit can be left to the results review section of the EMR. Example: a patient with renal disease may be important to mention the levels of K, Ca, BUN and Cr, but it may not be relevant to automatically add liver enzymes.  Just because a lab was part of a panel, does not mean it needs to be added.
  *   History: Try to stick to interim history only.  Past medical history, family history and social history along with a review of systems should be documented in the EMR but no longer need to be included in the provider note for outpatient E&M (inpatient coming in the future).  You can eliminate the use of smartphrases and templates that bring this information into your outpatient note.
  *   Exam: E&M documentation guidelines for outpatient services now only require a medically appropriate exam.  Now is a great time to update your exam templates to eliminate items previously included just to support billing.   Similar changes are anticipated for inpatient E&M in the future.
  *   Problems and diagnoses: You do need to specify problems addressed and cofounding issues for utilization review and coding. Issues not relevant to the current visit, however, can be left to the chart’s problem list.
  *   Radiology results: have a new result? Summarize it in your note to discuss. Do not copy the entire result into the note. Especially do not copy forward notes adding studies each time to substitute for results review. No one wants to read through 6-7 old scan results while reviewing a note. Instead create an entry in the problem list with the important findings.
  *   Copy forward: this enticing tool has led to many cases of practitioners copying the last note and then adding new material for the day.  This leads to each note being an ever-growing long interim summary where it is hard to filter out what is new and important. Clean out copied notes to just contain the accurate information for the visit/day- the rest of the material is already in the chart and should not be repeated.

________________________________
>From the Desk of the CMIO
Neal Seidberg, MD
seidbern at upstate.edu<mailto:seidbern at upstate.edu>
315-464-7507



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