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Written by: Darlene D'Altorio-Jones (1959-2015) on Thursday, December 6, 2012 Posted in: Inpatient Rehab

I often get the opportunity to listen to the workflows and ‘ideal’ aspirations of those that chart on a daily basis in healthcare because of my position at Mediware. I get to work alongside innovation driven individuals moving to the next step of rehabilitation documentation. Everyone has some skin in the game and each discipline has very specific expectations. After all, and in time, those individuals will find their way past the present maze of new and different process and fall into step with their day-to-day reality of treating the patient and successfully documenting the most salient points into the medical record. It’s the all important document that justifies everything said, done and accomplished in meeting the ultimate goals for our patients on the road to recovery.

No one person has more investment in a new project than the Chief Medical Information Officer (CMIO) of a facility. That is why when I heard the phrase “Note Bloat”  spoken by Joe Heaton, MD,  CMIO of SCL Health System, I smiled and wholeheartedly agreed; more is not better and sometime less is best!  But in this day and age with so many stakeholders for information and the high probability that some sort of review for quality, quantity and medically necessary care will be waged against our written words, how much is ENOUGH?

Are we truly versed well in our clinical didactic training to include the exact information to paint the clinical expertise and necessity of our care? Are the guidance of SOAP, DAR, DART, SBAR, etc., capable of capturing the most significant information that reflects the time spent at the side of the patient? Are the conditions of participation and quality assurance metrics specific enough to define the constitution of expectations to guide all clinicians appropriately for just the ‘right amount’ of information? And last but not least, are the rules and regulations for billing overestimated so much so that notes have become encyclopedic renditions a search engine couldn’t duplicate so that we receive payment for the care delivered? All the anxiety around all these points is what has fueled the angst of each clinician only wanting to spend time with the patient.  

Are you feeling overwhelmed yet? Most are and this reality has led to NOTE BLOAT –  information so overwhelming that those of us sharing in the care of the individual are having difficulty weeding out the specific information quickly. In addition, as we share in the care of the patient, we waste time finding the truly necessary information to guide our component care effectively and efficiently. Trending, reports, flags and summative data tactics are tools needed to help guide informatics. Use them, don’t avoid them. We need just enough information to populate guiding data that allows us to quickly assemble and summarize specifically toward the expected end result. Take the time to really understand expectations so that you can trim documentation specifically to meet the ultimate goals.  Define the problem/s, communicate the expected achievable result to lessen the barriers around those issues to successfully discharge and keep the team focused in meeting expectations. Demonstrate how your specific skill sets mitigate harm and manage and stabilize the patient so they are capable of handling their own care given the resources available to them. When barriers are resolved, the patient is discharged.

Most of all follow Dr. Heaton’s advice and avoid NOTE BLOAT. When stakeholders can’t see expected progression because it’s buried in insignificant and redundant information, your success is diminished and your boat is about to sink.

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