Progress Notes Shouldn’t Have to Be So Comprehensive

Why is it that every visit note has to rehash past medical and surgical history, active problems, allergies and sometimes even long narratives about the initial presentation of the problem at hand and long lists of prior testing?

In the electronic health record, when we start a new encounter, those things are usually right there in a scrollable sidebar. And when we print or fax completed office notes from the EMR, most systems could automatically include all those lists, if only as attachments.

Imagine the possible time savings and mental health benefits (less burnout) if, during visits, doctors wouldn’t need to click “import to note” a kazillion times, indication we had rigorously reviewed everything in the sidebar (because how much does anyone really think we can do in the few minutes available in each encounter for review of past medical, surgical, social history and so on?)

And during return visits, or just scanning old notes, we could quickly and easily catch up on the progress of the patient’s case if all the fluff didn’t gum up the chart note. Because in most notes in most cases, those things are fluff. If a diabetic has started on a new medication and they come back to review their blood sugar log, which is improved, and they report no side effects, those things we pretend to review in detail really are fluff. Of course we need to cover them in more detail with annual visits or with brand new problems, but most of what we do is following up on specific issues in the care of specific diseases.

Let us get right down to the purpose of the visit instead of trying to, or pretending to, do everything for everyone every single time they come in.