ACP offers recommendations for improved documentation

The American College of Physicians (ACP) has issued recommendations for improving clinical documentation in EHRs to combat 'note bloat'--overloading of extraneous data.

“Although computers and EHRs can facilitate and even improve clinical documentation, their use can also add complexities; new challenges; and, in the eyes of some, an increase in inappropriate or even fraudulent documentation,” according to a policy paper from the organization published in Annals of Internal Medicine. “At the same time, many physicians and other healthcare professionals have argued that the quality of the systems being used for clinical documentation is inadequate."

ACP cited 'note bloat' as a result of EHRs making “defensive documentation easier." Key findings and actions can be obscurred by all the irrevelevant documentation, aking the record "difficult and time-consuming to read." The excess documentation has not led to improved patient care, according to the paper.

“We are in danger of repeating history by overstructuring the clinical record and overloading it with extraneous data,” warns ACP. “Physicians must learn to leverage the enormous and growing capabilities of EHR technology without diminishing or devaluing the importance of narrative entries. Failure to do so will inevitably influence the way we think and teach, to the detriment of patient care.”

ACP said EHRs should effectively display prior information that shows historical information in rich context; supporting critical thinking; and enabling efficient and effective documentation.

The paper proposes a set of seven policy recommendations clinical documentation and five recommendations for EHR system design to support clinical documentation. All were approved by the ACP's governing board. 

The EHR system design recommendations include facilitating longitudinal care delivery as well as care that involves teams of clinicians and patients that are managed over time; documentation must support clinicians' cognitive processes during the documentation process; and EHR systems must facilitate the integration of patient-generated data and must maintain the identity of the source.

Read the complete paper.