Clinical documentation is one of the most time-consuming aspects of a clinician’s daily workflow, yet also one of the most important. Progress notes took hours as they were handwritten on loose-leaf papers, and then filed away amongst a myriad of manila-folder patient charts. Today, with electronic health records (EHR) as the norm in health care, electronic progress notes have also become a critical component of efficient clinical practice workflow, however, most digital progress notes design does not reflect optimal clinician documentation patterns, and leaves much to be improved.
CLINICIAN NOTATION PATTERNS
For many clinicians, documentation is often fragmented, meaning that they frequently face a number of interruptions by having to transition between pages throughout the course of their notation process. Usually, this involves reading previous patient notes written by other physicians, retrieving clinical results, and other relevant information pertaining to a particular patient. One study found an average of over 10 transitions per note. This revealed that most clinicians’ elicit a synthesis documentation style, rather than composition, meaning that they are more likely to write in smaller modules or blocks as they review information, rather than in one uninterrupted session, relying on memory.
The problem is that most EHR systems’ progress notes are designed to support uninterrupted composition style of documentation and doesn’t reflect the realities of clinical practice. A modular documentation format better supports the natural workflow practices of busy clinicians.
ELECTRONIC DOCUMENTATION FACILITATES COLLABORATION
Improving clinical processes requires documentation to be done in a way that facilitates and streamlines collaborative care; electronic progress notes grants other clinicians and health care professionals a way to easily extract the clinical information they require without creating any disparities in a patient’s episode of care. According to a report by Canada Health Infoway, 63% of Canadian nurses enter and retrieve clinical notes electronically; documentation in a synoptic format allows varying parties to quickly and easily pull clinical data as required, as opposed to having to read through long composition-style progress notes.
FACILITATE PATIENT CARE PLANS
This can also be beneficial in determining an appropriate patient care plan, including predicting or anticipating discharge dates upon admission. One study investigating patients in the neonatal intensive care unit (NICU) found that key clinical features in the patient’s daily progress notes provided an accurate method for predicting when the patient was nearing discharge from a medical perspective. This type of predictive model can also be implemented for adult patients using their hospital admission and daily progress notes.
The clinical progress note is one of health care practitioners’ most valuable, yet underrated tools, and must be respected enough to be improved upon and used to the full extent of its potential. Handwritten, illegible, misinterpreted notes are no longer a sufficient means of disseminating information that could mean the difference between life and death for a patient. Modernizing and optimizing progress notes is necessary to ensure we’re delivering the best care for those who need it most, while improving the workflow of those who of deliver that care day in and day out.
- Temple, M., Lehmann, C., Fabbri, D. Predicting discharge dates from the NICU using progress note data. Pediatrics 2015; 136:e395-e405
- Mamykina, L., Vawdrey, D., Stetson, P., Zheng, K. Hripcsak, G. Clinical documentation: composition or synthesis? J Am Med Inform Assoc 2012; 19:1025-1031
- Rodriguez-Vera, J. et al. Illegible handwriting in medical records. Journal of The Royal Society of Medicine 2002; 95:545-46 Retrieved from: http://jrs.sagepub.com/content/95/11/545.full.pdf+html
- Canada Health Infoway. Report on Digital Health: Clinician embracing digital health. 2015; Retrieved from: https://www.infoway-inforoute.ca/en/component/edocman/2817-infographic-report-on-digital-health-clinicians-embracing-digital-health/view-document?Itemid=101