That well-known but medically complex patient is back in your emergency department (ED). He was seen by your colleague last week and had a big workup, so you pull up her clinical note in the electronic health record (EHR) to review her previous assessment and plan. But, to get to those pearls of information, you’ve got to sift through endless labs and radiology reports, imported meds, and past history. The outpatient workup has continued as well, so it’s not quite clear what data in last week’s ED note is current. Just as you’re making progress, your nurse flags you over to see a different patient.

Medical notes have become plagued with unnecessary information, making them difficult to read, and costing valuable time and attention. “Note bloat” is a distinctly American phenomenon, and occurs across specialties, but longer notes—full of imported results and other data—affect emergency physicians when concise, relevant clinical communication is optimal to make quick decisions on patients with whom we do not have an established relationship. Emergency physicians are often on the receiving end of bloated notes from consultants, or prior discharge summaries—and we also participate in their creation.

Note bloat is multifactorial, but has been aided and abetted by the proliferation of EHRs, which make it easy to import past history, medication lists (often outdated), vital signs, lab results, radiology interpretations, boilerplate phrases, and other elements of a patient’s care into a note via content-importing technology (CIT). This is often done out of the mistaken belief that complete data is necessary or appropriate for billing and coding or to mitigate malpractice risk. However, these superfluous details add little value and make notes harder to parse in the ED.

In January 2023, we will see landmark changes to E/M coding rules (see the article: https://www.acepnow.com/article/2023-documentation-guideline-changes-for-ed-e-mcodes-99281-99285/) from the Centers for Medicare and Medicaid Services (CMS). With these changes, emergency physicians should revisit appropriate documentation–what’s needed for accurately capturing our patient care and medical decision-making and what’s unnecessary and detrimental to clinical communication. A more judicious use of EHR importing capabilities, and use of tools that support linking and prompt summaries should help us make the most of the 2023 coding changes. If physicians do this right, notes will become more useful and readable, without hurting reimbursement or increasing liability.

In recent months members of ACEP’s Health Information Technology Committee, Reimbursement Committee, Coding and Nomenclature Advisory Committee, and Medical-Legal Committee joined forces to author a white paper on this topic, Addressing Note Bloat: Solutions for Effective Clinical Documentation. The authors describe best practices to minimize note bloat and improve clinical communication.