Craig Joseph, MDApr 29, 2024
What needs to be in a good progress note? There's a whole lot of controversy about that. Want to know what DOES NOT belong in a good progress note? Ahhh, that we can help you with! Join this #AMIA webinar with me and Aaron Grigg, MD. #NoteBloat https://amia.org/webinar-library/write-notes-you-want-read-not-ones-your-biller-used-require
Write the Notes You Want to Read, Not the Ones Your Biller Used to Require

Who is in control of the content of the progress note? What is truly required for billing purposes and what are we holding onto for the sake of tradition/habit? How can you regain control of your note and remove the bloat that has built up over the years?

AMIA - American Medical Informatics Association
Jennifer Hamilton, MD PhDMar 28, 2024

An elderly patient of mine is being discharged from an area hospital today, after her 2nd admission in a few weeks. Good news: I can already see her discharge summary from the comfort of my home. Bad news: because of how sections are only added to, never deleted, it includes plans for hyperkalemia (recent) and hypokalemia (2021); follow-up of bowel injury (recent) and need for screening colonoscopy (from years ago -- even though its a Bad Idea right now).

#NoteBloat #SignalToNoise

Craig Joseph, MDJul 12, 2023
I love me some of Epic's Cosmos data! They write: "We evaluated 1.7 billion clinical notes written by 166,318 outpatient providers . . ." The numbers are staggering, actually. Oh, and it turns out #NoteBloat is alive and well, sadly.
https://epicresearch.org/articles/two-years-after-coding-changes-sought-to-decrease-documentation-notes-remain-bloated
Two Years After Coding Changes Sought to Decrease Documentation, Notes Remain ‘Bloated’