EDRs have changed a lot of workflows and processes in dental practices. Whether you like EDRs or not, you have to acknowledge one thing – they’ve made notes legible! Healthcare professionals are notorious for illegible handwriting but it looks like EDRs have finally solved legibility issues.
Unfortunately the ease of adding information to the note field in an EDR has given rise to a whole new problem – note bloat. Instead of insufficient information in the patient record, dentists now have too much data. Note bloat can lead to serious problems. Research has indicated that doctors start ignoring bloated notes because it is a waste of valuable time. They’ve to go through multiple pages of unnecessary data to find the one thing they’re looking for. Doctors rarely read their own notes, so mistakes go uncorrected.
Why Do We Have Note Bloat?
Switching to electronic records has encouraged note bloat. Many EDRs offer multiple input methods like dictation, autocomplete, list pickers, copy-paste etc for ease of use. But the same tools encourage users to add information that is redundant, useless or even outright incorrect. Copy and paste actions lets the dentist easily add information but sometimes leads to inaccuracies. Autocomplete is a valuable tool but users may end up with wrong details because 2 words are spelled similarly.
Dentists generally don’t write multiple pages of notes but with the assistance of software, it’s quite tempting to cram as much information as possible into the notes field for ‘completeness.’ After all, having too little data is worse than having too much right? Another issue is that users include data that is already available elsewhere in the record like x-rays, vital stats, images etc. In essence, the notes filed has become a catch all place for the dentist to include all information – whether it is needed or not.
How to Avoid Note Bloat
Implement Best Practices
Every clinic or hospital should have guidelines and best practices for the information that goes into the notes. The best practices should cover issues like what data should be included, what can be ignored, whether to include a summary etc. You can create custom templates for different departments to help users keep the notes section organized.
Minimize the Use of Copy/Paste
It is very tempting to use copy paste actions but they often lead to errors. Copying from a previous visit of the same patient carries the risk of overlooking changes or carrying forward wrong information. Dentists can sometimes forget to change the relevant information or add details that are particular to this visit.
Do Not Duplicate Data
Is the information you are about to enter already available somewhere else in the patient record? Then it doesn’t belong in the notes. Users need to get out of the habit of relying solely on the notes for everything. Lab results, x-rays, images, vital stats, medication and allergy lists already have their place in the record. There’s no need to add them again in the notes section.
Change the Note Format
Traditional notes follow the standard SOAP (subjective, objective, assessment and plan) format. When another doctor is going through the notes, the assessment and plan are the most relevant sections. However they’re buried underneath pages of test results, x-rays and other information. Some clinics are experimenting with changing things around like putting the assessment and plan first. The APSO format puts the important sections upfront, making it easy to find later.
There are ways to overcome note bloat but the important thing is to be aware that it happens and prepare for it. With some planning and effort, the notes section can once more become a valuable asset to doctors.