Cedars-Sinai Medical Center

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A BI-WEEKLY PUBLICATION FROM THE CEDARS-SINAI CHIEF OF STAFF Aug. 16, 2013 | Archived Issues

New Guidelines Aim to Increase Quality of Inpatient Progress Notes

A task force commissioned last year by Cedars-Sinai's Health Information Committee to improve the inpatient progress notes physicians enter into CS-Link™ has created evidence-based guidelines defining best practices.

The guidelines, approved by the HIC — a medical staff committee — and the Medical Executive Committee in April, address what constitutes a quality progress note at Cedars-Sinai, said Joe Kim, MD, associate medical director of Quality Improvement.

"It used to be a progress note was communication from one doctor to another, but today we're seeing it not only as a way of communication but as a legal document and paperwork for billing and coding," said Kim, who serves as chair of the task force.

The evolving functions of the progress note means the note must efficiently convey information that is clinically accurate, legally protective and billing compliant. This wide usage, which also encompasses social services, makes appropriate entry into CS-Link a vital part of the process, Kim said.

The subcommittee created a scoring system, or tool, based on physician input to identify quality progress notes and any challenges clinicians face while creating the document for patients' electronic medical records, he said.

The guidelines and scoring tools were initially rolled out in the Department of Medicine, the Division of General Internal Medicine and the Neonatal Intensive Care Unit. A template for a progress note based on the new guidelines is available from the Department of Medicine.

Generally speaking, progress notes provide a brief daily account of patients and their illnesses, and of developments in their diagnosis, problem list and treatment, for all of those who share in their care. While the information is straightforward, the document can become complicated.

For example, the task force found that some physicians were copying and pasting too much information, which was weighing down the progress note.

"In this world of the EMR (electronic medical record), we now have SmartTools that make it easy to pull in or copy forward information from other parts of the medical record, which can clutter the progress note or make it longer than necessary and as a result degrade the quality," said Peggy Miles, MD, associate director of the Division of General Internal Medicine and a member of the task force on progress notes. "The development of these guidelines should help physicians take advantage of the information within EMRs in an efficient and meaningful way."

"The electronic medical record presents extraordinary opportunities to improve physician documentation and efficiency," Kim said. "However, indiscriminate use of EMR functions may unnecessarily clutter notes, lengthen documents and degrade the quality of the EMR.

"The ideal progress note serves as a concise interpretation of clinical information and conveys the analytical decision making of the clinician."

In addition, the task force recommends that guidelines for progress notes be included in the resident orientation booklet. Medical students are taught the SOAP (Subject Objective Assessment Plan) format for medical evaluation entries in patient records, Kim said. These entries can become "top heavy" with redundant information within the EMR, he said.

To address that, Cedars-Sinai's guidelines for progress notes recommend a variation of the SOAP format. In the APSO format, the most pertinent and current information is placed at the beginning of the note. The new format has been well received by the residents.

Kim said the next step is wider rollout of the guidelines, with HIC physicians supporting adoption by more clinicians.

"Doctors are very busy and prefer to spend more time with patients and providing medical care," Kim said. "These guidelines can assist doctors in using this technology to their advantage."