Progress Notes and the Enlarging Assessment/Plan Sections

Problem:

I have seen a common pattern popup over the last ten years in daily inpatient progress notes, specifically the assessment and plan section. This only occurs in copy-and-paste notes, and I don't have a good name for it at the present time.

Here is a fictional example of a partial A/P:

Day 1:
GI Bleed 
    -has been going on for at least a week before admission
    -GI requests holding anticoagulation for a-fib

Day 2:
GI Bleed 
    -has been going on for at least a week before admission
    -GI requests holding anticoagulation for a-fib
    -GI performed colonoscopy, no clear source of bleed.  
    -PPI q12h for now

Day 3:
 GI Bleed 
    -has been going on for at least a week before admission
    -GI requests holding anticoagulation for a-fib
    -GI performed colonoscopy, no clear source of bleed.   GI also performed EGD, small ulcer in fundus, no active bleeding.  
    -PPI q12h for now

Day 4:
  GI Bleed 
    -has been going on for at least a week before admission
    -GI requests holding anticoagulation for a-fib
    -GI performed colonoscopy, no clear source of bleed.   GI also performed EGD, small ulcer in fundus, no active bleeding.  
    -PPI q12h for now
    -patient had hematemesis, and GI performed another EGD, noted a large duodenal ulcer, cauterized



Essentially, the previous progress note is copied into the current one, and additions (with some slight alterations of previous details) are made.  Now imagine this pattern goes on for 11 or more days. On day 21, the A/P section for the progress note is insanely verbose. 

I am not a fan of this style for a few reasons.
1. Assessment and plan are sort of mixed together randomly (which is not unique to this pattern)
2. The bigger culprit: CLUTTER!

This pattern junks up the assessment and plan with a lot of repeat, old data.  In handwritten notes, the plan would be a line or two or three.  It would not recap every single development.  One of my colleagues tells interns/residents not to type anything that they would not have written by hand in the pre-EMR days, and this is good advice.

But there IS a very beneficial aspect to this note style.  For anyone who has had to write a discharge summary on a patient they had for only a brief part of the patient's overall stay, this sort of sums everything up for them. 

So how does an EMR handle progress notes while making things easy for the provider who writes the discharge summary?

Solution 1:

One possible solution: for the A/P each day, the provider only puts what is relevant for the current day.   The EMR would recognize the A/P for each problem, and could provide the provider with a summary of care for each problem (ie a compilation for the plans for that section of each daily progress note).

Summary example:
Problem : GI bleed
Day 1: 
Unclear source; has been going on at least a week before admission.
-holding anticoagulation
-GI will perform colonoscopy

Day 2:
Colonoscopy without clear source of bleed. 
-will monitor
-PPI IV q12h

Day 3:
EGD with small ulcer in fundus, unclear if this is source of bleed.
-will continue to monitor
-PPI IV q12h

Day 4:
Patient had episode of hematemesis, and GI performed another EGD.  Noted large duodenal ulcer, cauterized.  
-will continue PPI q12h
-will monitor


So while the summary may be longer when compared to an individual progress note, it is much more clear regarding the assessment and plans for each individual day.  And the progress notes for each day are not cluttered.

Solution 2:

This would still employ a "clutter-free" progress note, but it would involve another document...a wiki-style perpetually edited "Summary of Stay" document.  This is essentially a Discharge Summary document that is started when the patient enters the hospital, with each problem having its own section.  Every day (as needed), the document is edited to include the recent developments.  When it is time to discharge the patient, the discharging provider has to simply make a few cosmetic edits to the document.