Quality Documentation Tip - Using Active Document Links
Excessive or inappropriate use of copy-paste is a common contributor to "note bloat". It is better to refer to prior notes and use the current note to highlight differences between what is observed and what was observed.
Manual references (citing the prior note type, service and date) are always possible.
More powerful are "active" references that include a link to the prior note so that readers can quickly bring it up for review while examining the new note.
- With a patient chart opened to any encounter in Hyperspace, select the "Chart Review" activity (usually the leftmost tab) and then the "Notes" section.
- Scroll (or, if necessary, use the Notes filters, sorting or quick filters) to find a prior note of interest.
- Position the cursor/pointer over the note of interest, then right-click to reveal a pop-up menu and select the "Copy Links" option.
- Return to the new note being edited, position the cursor in the text at the location where reference is made to prior documentation and then use "Paste" (right-click menu or keyboard shortcut) to insert an active link.
- When pended, saved or signed, the new note will have a hyperlink that can be selected to allow the reader instant access to the referenced documentation.
Use of active document links can reduce overall note size and improve the clinical utility of change documentation.
BONUS! The same technique can be used to reference laboratory, imaging and other results/information listed in Chart Review tabs.