Clinical notes are too long. Here are 7 ways to make them shorter.
Seventeenth century mathematician and philosopher Blaise Pascal is famous for saying, “I would have written a shorter letter, but I did not have the time.” Centuries later, the same remains true of clinical notes – despite an ongoing federal push to make them shorter.
An analysis published this summer by Epic Research, evaluating 1.7 billion clinical notes entered over a three-year period, concluded notes now exceed 5,000 characters. (Roughly speaking, that’s 1,000 words, or nearly twice the length of this article.) This marks an increase of 8.1% from May 2020.
Clinical notes have only been getting longer. A 2018 study pegged their average length at nearly 700 words, or 3,500 characters, and that length had more than doubled since 2009. Clinical notes in the United States are three to four times longer than those in other English-speaking countries, the study added.
Two trends appear to drive longer notes. One is federal regulation. In 1995 and 1997, the Centers for Medicare & Medicaid Services released guidelines for evaluation and management services (E/M) that required “extensive documentation,” as the American Health Information Management Association put it, to ensure proper payment from insurers. Though CMS reversed course in 2021, many physicians remain leery of writing shorter notes, AHIMA said.
The other is easy reuse of information within the electronic health record (EHR). A 2021 study found less than 30% of the text in clinical notes to be directly typed, original information. The remaining 70% consisted of text carried over from templates or copied from a previous note. This saves time – Epic Research found clinicians spending 11% less time writing notes, despite notes being 8% longer – but presents concerns, as templates and copied text often contain information that’s outdated, irrelevant, or otherwise inaccurate.
Reducing the length of notes requires a multifaceted approach that focuses on better documentation and better use of EHR technology. Steps include:
- Rethink templates. As of 2021, documenting medical history or physical examination isn’t required to select E/M Current Procedural Terminology (CPT) billing codes. AHIMA recommended updating documentation templates to include only “simplified, pertinent information.”
- Consider standards. Even with templates in place, clinicians have their preferred methods of documentation. Creating standards for what should and shouldn’t be entered will help the entire organization embrace brevity.
- See what the EHR can do. To cut down on copy and paste, EHR vendors are adding features that create links to patient history within a note instead of copying it in its entirety. This makes information available without creating note bloat.
- Update key histories. Enabling links to patient histories, problem lists, and medication lists within clinical notes means it’s critical for this information to be accurate. If clinicians know the information they’re linking to is up to date, they’re more likely to do it.
- Use SOAP or ASPO. The Subjective, Objective, Assessment, and Plan note, and the more modern Assessment, Plan, Subjective, Objective note, prioritize clinical data relevant to the reason for a patient’s visit and de-emphasize unrelated details.
- Educate new hires. The 2021 study showed residents and fellows wrote notes that were 26% longer than non-trainees. Shorter tenure at an organization was also directly proportional to longer notes length. Let new clinicians know they don’t need to over-document to prove their competence.
- Explore new technology. Incorporating generative AI into the EHR or using digital scribes can help summarize clinical notes, medical history, and medication lists. This reduces much of the manual labor associated with documentation.
Brian Eastwood is a Boston-based writer with more than 10 years of experience covering healthcare IT and healthcare delivery. He also writes about enterprise IT, consumer technology, and corporate leadership.