Did the new CMS 2023 documentation guidelines for Emergency Medicine reduce “note bloat”?


Did the new CMS 2023 documentation guidelines for Emergency Medicine reduce “note bloat”?

The Study

CMS guidelines for reimbursement of emergency department visits changed in January, 2023. In an attempt to reduce documentation burden on clinicians and hopefully reduce burnout, the guidelines reduced the number of elements required in an emergency department note. The focus shifted away from the number of elements documented and instead focused on the documentation of medical decision making.

In December 2023, the Annals of Emergency Medicine published a study to determine if these changes made any difference in reducing “note bloat”, the practice of filling clinical notes with extraneous information required for billing, causing them to be lengthy and difficult to read with little impact on clinical care.

The Measure:

The study took place at Geisinger Health System, which includes 9 emergency departments using one electronic health record (EPIC). Emergency department notes from Feb 2018 – June 2023 were retrospectively reviewed for content and character count. Additionally, clinician time spent documenting was also compared.

1,679,762 notes were reviewed

  • 302,101 – 2018
  • 307,151 – 2022
  • 154,655 – 2023

The Intervention:

Beginning January 2023, when the new CMS guidelines took effect, the hospital system made three changes to the note templates for all emergency departments:

  1. Patient’s medical, surgical, social, and family histories were removed from the templates and replaced with hyperlinks.
  2. Lab and radiology data, previously added manually by clinicians, was also replaced with hyperlinks.
  3. Some sections of the template were made optional and embedded where they might be needed. For example: the review of systems was moved to the history of present illness section and made optional.

What did they find?

  • Before the interventions:
    • The average note from 2018 and 2020 contained between 1783 and 2067 words
    • The average time spent documenting a note in 2020 was 4.80 minutes.
  • After the interventions:
    • The average note from 2023 contained 1,195 words
    • The average time spent documenting a note in 2023 was 4.44 minutes.

The intervention resulted in a reduction of 872 words and 0.36 minutes of charting time per note.


Embracing new guidelines and practices, we reduced the length of ED provider notes by 872 words. Despite this, the time clinicians spent documenting did not change significantly. We provide an early report of success in reducing note bloat in the ED to help guide future efforts to reduce overall documentation burden.

Questions Remaining?

  1. Did the change in documentation result in decreased stress for providers (the whole point behind the reduction in burdensome documentation)? Unknown
  2. Did the reduction in information contained in each note cause any clinical (patient) care problems for providers ? Unknown

It was an extraordinary effort by the authors to pull together a multidisciplinary team of physicians and coding representatives, edit templates used by 9 emergency departments, and measure changes in length of notes and time required to complete them. It gives me hope that other health systems will examine their own templates and continue the process of reducing documentation burdens for clinicians of all specialties.

Read The Original Article

Marshall K, Strony R, Hohmuth B, Vawdrey DK. New Coding Guidelines Reduce Emergency Department Note Bloat But More Work Is Needed. Ann Emerg Med. 2023 Dec;82(6):713-717. doi: 10.1016/j.annemergmed.2023.07.023. Epub 2023 Aug 30. PMID: 37656109.

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