Part 2: Siloed Documentation in a Collaborative World
“The clinical note, while once a useful tool, has become a burden in today’s healthcare system. As healthcare becomes more complex and team-based, our documentation systems must evolve to keep pace.”
The clinical note has been a cornerstone of medical documentation for decades. It’s the primary method to record patient encounters, capturing essential details from each visit. But what exactly is a clinical note? At a fundamental level, a note is a bundle of facts, organized by time, author, and clinical thread. In other words, each note reflects a snapshot of a patient’s condition at a specific moment, documented by a specific clinician, and tied to a specific visit or interaction.
While this structure may have worked in the past, the note paradigm is increasingly out of place in today’s healthcare environment. This traditional form of documentation, a holdover from the paper era, no longer fits the collaborative nature of patient care. It leads to a chaotic and fragmented chart, in which redundancy and scatter impede the efficiency of healthcare teams.
In this post, we’ll explore how notes — organized around visits and not around problems — create information chaos in healthcare and why we need to move toward a new documentation model.
The Limitations of the Clinical Note
At its core, the clinical note organizes information by author, time, and clinical thread. This means that every note is tied to a specific encounter or moment, authored by one clinician, and focused on a particular aspect of patient care. But this structure is also what causes many of the problems we face today.
Let’s break down the key issues caused by the current model:
Redundancy: Because notes are organized around clinical visits rather than around specific medical problems, the same information is often repeated across multiple notes. For example, a patient’s history, medication list, or physicians’ clinical reasoning may appear in note after note, creating redundant data that bloats the patient’s chart and makes it difficult to sift through relevant information.
Fragmentation: In the current documentation paradigm, information related to a single problem gets scattered across multiple entries. A single issue, like managing diabetes, could be referenced in notes from the primary care physician, an endocrinology nurse practitioner, a podiatrist, and an inpatient bedside nurse, each with its own timeline and perspective. This scatter makes it challenging to get a clear, unified picture of the patient’s condition.
Lack of Collaboration: Notes are written by one clinician. This individual-centric documentation system discourages collaboration. Other clinicians must add their own notes, reinforcing silos of information and making it harder for teams to work together seamlessly.
These limitations don’t just cause minor inconveniences—they create an environment where critical information can get misinterpreted out of context or buried under layers of outdated data. The problem is that the underlying structure of how we bundle information doesn’t align with the way we deliver care.
The Clinical Note Causes Information Chaos
The failures of note-based documentation are best understood through the lens of information chaos (Beasley et al., 2011) which describes the breakdown of information management in electronic health records (EHRs). There are five components of information chaos, all of which are exacerbated by the way we use notes:
Information Overload: Too much information in the chart makes it difficult to find what’s relevant. With every new encounter, clinicians must sift through pages of redundant information that is copied forward, in theory to reduce information loss. This wastes time, ends up obscuring important data, and can increase and propagate errors.
Information Underload: Conversely, because notes are tied to specific encounters, they often miss critical updates or fail to provide a comprehensive view of a patient’s condition. When key information is missing, clinicians are left without the full picture, leading to information underload. We talk more about the tradeoffs between agglomerative and contextless charting in another post here.
Information Scatter: With each clinician documenting in separate, time-bound notes, important details about a single problem can end up scattered across the chart. This fragmentation makes it difficult to track a patient’s progress or understand the evolution of a particular condition.
Information Conflict: When different clinicians document conflicting interpretations of the same patient data in separate notes, it can lead to information conflict. Without a centralized, problem-based view, contradictions may persist across the chart without clear resolution. And, while contradictions in the chart are OK - clinicians can disagree about a diagnosis or plan - information scatter makes it so these conflicts may not be apparent.
Erroneous Information: Once an error is documented in a note, it’s difficult to correct. Clinicians who review past notes may rely on outdated or incorrect information, perpetuating errors throughout the patient’s chart.
Each of these components contributes to a sense of disorganization in the EHR, turning what should be a powerful tool into a source of frustration. The clinical note—fragmented, redundant, and isolated—lies at the heart of this chaos.
Why Notes Fail in Collaborative Healthcare
Healthcare is a team sport. Whether you’re working in a hospital or a clinic, multiple clinicians contribute to each patient’s care, often across specialties and departments. However, the clinical note, with its author-and-time-centered structure, fails to support this collaborative reality.
In a typical case, a patient may be seen by a primary care physician, a cardiologist, and a rehabilitation specialist. Each clinician documents their own perspective in separate notes, resulting in siloed information. When a new development occurs — a new physical exam finding or an expanded differential — it will not be reflected consistently across all notes. Each clinician documents what they know from their own encounter and it can be difficult or even impossible to know which note in the patient’s chart really reflects their current state. In this case, your impression of the patient is highly dependent on which note you clicked first and not how they are actually feeling.
This system was designed for a time when clinicians worked more independently. Today’s healthcare, which is increasingly interdisciplinary and collaborative, demands a documentation system that allows for updates from all providers involved in a patient’s care. The note-based model, centered around individual encounters, simply doesn’t support the kind of collaboration needed to provide high-quality, coordinated care.
The Future of Medical Documentation
If clinical notes, organized by time and author, are no longer sufficient, what should the future of documentation look like?
We believe the solution lies in a shift toward problem-based documentation — a model where information is organized around medical problems rather than around individual encounters or clinicians. Here’s what that might look like:
Problem-Based Organization: Instead of structuring the chart around visits or clinician entries, documentation could be organized around specific problems or conditions. This would create a unified view of each problem, making it easier to track the evolution of the patient’s care over time.
Collaborative Workspaces: Multiple clinicians could work together in a shared, evolving patient record, contributing to the documentation and allowing the chart to support decision-making instead of only recording it. This would allow a patient’s chart to better reflect real-world team collaboration which often consists of faxed notes, phone calls, and accidental conversations in the hallway. While in-person conversations remain the mainstay of clinical collaboration, bringing this type of work online can speed up collaborative decision-making and capture the decision-making process, making it easier to adjust the plan over time as new data become available.
Growth Over Time instead of Copy Forward: This combination of problem-based charting and collaborative workspaces means documentation can truly evolve with the input of multiple stakeholders, even the patients themselves. With a note structure that supports small updates without starting a new note, problem histories can grow in ways that better reflect the clinical reality and move beyond the current paradigm of copying forward the last note, with all its attendant problems.
By shifting to a more collaborative, problem-oriented model, we can break free from the constraints of traditional notes and create a documentation system that truly supports the way we care for patients today.
Conclusion: Time for Change
The clinical note, while once a useful tool, has become a burden in today’s healthcare system. Organized by time, author, and thread, it leads to information chaos — fragmentation, redundancy, and a lack of collaboration. As healthcare becomes more complex and team-based, our documentation systems must evolve to keep pace.
It’s time to reimagine how we document patient care. By moving away from the traditional note and embracing a collaborative problem-based approach, we can reduce chaos, decrease the cognitive burden on physicians, and build a system that truly supports patient care.
