The Ideal Clinician Note and Barriers to its Creation

By Brian R. Jacobs, MD, FHIMSS (eClinicalWorks)

This is the third in a blog series highlighting the discussions from the 2022 EHRA & HIMSS Physician Committee Summit: Meaningful and Streamlined Documentation.

When the EHRA and the HIMSS Physician Committee came together for a virtual Summit on meaningful and streamlined clinician documentation, three multidisciplinary breakout groups addressed key issues related to the topic. These included the ideal clinician note and barriers to creating such notes, which is the focus of this blog, as well as the exchange of the ideal note between providers and barriers to such exchange, and the specific EHR-related barriers to creating and/or consuming the ideal note. 

As noted in Documentation Burden: Addressing the Elephant in the Room, few disagree “that the focus of the note should be on the clinical encounter and ensuring the information entered clearly captures the problem, medical decision making, and ultimately help with communication between clinicians and our patients while meeting coding and regulatory compliance requirements. To continue this theme, this third blog will highlight the findings of the first Summit breakout group – which included physician, nursing, informatics, and EHR vendor representatives – discussing the topic of creating the ideal note, as well as the various barriers to creating that ideal note.

Our October 2022 breakout group arrived at a consensus opinion that an encounter note should at the very least be one which is concise and contains accurate information – a note from which multiple stakeholders will derive value.

Our breakout group first reviewed the American College of Physicians and EHRA 2021 State of the Note Summit and ideal note recommendations. We noted that this Summit tackled the issue of the bloated note which is overly focused on billing, and produced strong recommendations on shorter and more relevant notes. However, these recommendations did not specifically address several issues, including:

  • The documentation needs of other relevant stakeholders in the note
  • Whether one version of each encounter note is acceptable or if multiple versions are needed (i.e., patient, physician, nursing view, coder views)
  • Individual clinician barriers to creating the ideal note, and
  • Organizational barriers to acceptance of the ideal note

Our October 2022 breakout group arrived at a consensus opinion that an encounter note should at the very least be one which is concise and contains accurate information – a note from which multiple stakeholders will derive value. Furthermore, the group consensus included a desire for notes to be output in APSO (Assessment, Plan, Subjective, Objective) format beginning with the assessment and plan, with subjective and objective information to follow. Importantly, the group felt that the note should be devoid of repetitive information. For example, there is no need to include information such as immunization status, allergy information, medication lists, or normal laboratory results in the note when this information exists a click away elsewhere in the EHR.

The breakout group then turned its attention to identifying individual and organizational barriers to the establishment of the ideal note culture. Clinicians cited decades of expectations and pressure which likely contributed to the current state of bloated, copy-forward, and time-consuming documentation. Despite recent recommendations on concise note composition, clinicians may still perceive that a lengthier note is a better note; one which is more supportive of billing, coding, auditing, and payer expectations, that is less likely to be questioned, and provides better coverage in medico-legal situations. The environment fostering such thought likely began with medical school training, then perpetuated in residency, and reinforced by expectations of organizational billing and coding staff. All three areas represent potential target areas for change in practice. 

Furthermore, the group felt that nursing documentation often represents a rich source of important information which should complement physician notes while avoiding redundancy. Finally, organizational leadership will be essential for effective change in clinician documentation. Specifically, leadership is needed to address existing clinician concerns, resource and time requirements, and in aligning various stakeholder knowledge and misconceptions.

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1 Comment

  1. Tyler Haberle MD FACP FAMIA, Associate CHIO, Intermountain Healthcare

     /  January 20, 2023

    As long as clinical documentation is used to derive quality measure performance, and until reform of billing and coding criteria further simplifies auditable requirements, the ideal provider documentation will remain ideal. This is a good framework to assist with the ongoing efforts to reduce documentation being used for quality reporting and reducing other administrative requirements from the notes.

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