Writing effective clinical patient notes is more than just a documentation requirement. It’s a form of communication that informs patients and colleagues about what happened during a medical encounter.
Keep it brief.
It’s a common mantra among junior doctors to strive for perfect c, especially in the context of malpractice claims. However, the most important purpose of progress notes is not to be a legal document or service document; it’s a form of communication.
Progress notes should summarize the main presenting issues and all relevant information related to those symptoms or events (e.g., their onset, chronology and quality). Also, record if the patient has complied with previously documented plans of action and their effect on the symptoms.
One tip on how to write clinical patient notes is to avoid writing excessively long notes or “note bloat.” This can make the progress note difficult to read and skew the overall impression of your professionalism. Also, avoid misspelling words or poor grammar in the progress notes; this gives the impression that you need to care more about your patients and their medical records to take the time to proofread your work. Lastly, be sure to date and sign each entry.
Be thorough.
A patient note is a tool for communication between healthcare practitioners. It also is a critical component of medical billing and reimbursement. As such, the documentation must be thorough and accurate.
One of the most basic principles of writing a clinical patient note is to be comprehensive. Documenting all relevant information, including the patient’s background history and current health status, is important. This information is crucial for future providers to understand the context of your patient’s condition.
In addition, it is important to be objective when describing the patient’s condition. This means avoiding personal opinions and venting in your notes. Instead, focus on measurable and accurate facts, such as a patient’s vital signs or the findings from a physical examination.
Finally, it is important to write your clinical patient notes promptly. This helps ensure you have the correct details to complete the necessary paperwork and that all your patients receive high-quality care. It also allows for quick and easy readability, which is important when your notes are shared with other health professionals or reviewed by a regulatory body.
Be organized.
A common saying in healthcare is, “If it’s not recorded, it didn’t happen.” While delivering care to patients may be the most visible aspect of the industry, many other essential processes are occurring behind the scenes – like clinical patient notes.
To be effective, clinical patient notes need to be organized. The first step is establishing a documentation workflow that works for your practice. This could include a standard template such as SOAP, which divides relevant information into the different aspects of a patient encounter.
Once you’ve established a workflow, making it a habit of recording your clinical patient notes is important. This will help to ensure that your messages are accurate and consistent. Having a regular schedule can also reduce the stress and fatigue of clinical note-taking.
Finally, it’s important to be mindful of HIPAA guidelines when writing clinical patient notes. This means avoiding medical jargon that could be difficult for the average person to understand. Doing so will elevate the transparency of patient records and enable patients to engage with their health data more fully.
Be concise.
Since patients have a right to their medical records, clinicians need to make these notes accessible and easy to understand. This will allow for continuity of care between different providers and ensure that patients have all relevant information should they seek a second opinion.
It is often helpful to use a format such as SOAP when writing your progress notes to structure the note in an easily digestible manner. This will help avoid unnecessary details, which can distract the reader. It is also important to remember that the note may be read by other healthcare team members, patients, and their loved ones. This means that your writing should be professional and free of subjective language.
As a final point, it is important to remember that progress notes should focus on objective, repeatable and measurable facts. For example, it would be risky to document that a patient is an alcoholic or abusing drugs unless objective evidence supports this conclusion (e.g., a physical exam or other evidence).
Be readable.
We’ve all heard the phrase, “If it isn’t documented, it didn’t happen.” The medical record serves as a legal document that may be scrutinized in the event of malpractice and, more importantly, supports reimbursement.
The clinical patient note records the encounter between a healthcare practitioner and their patient. It’s a vital part of the patient’s health history and provides important information for future healthcare practitioners working with the patient.
For that reason, clinical notes must be readable. This means using language that’s understandable to readers and avoiding jargon or abbreviations that might not be familiar to other clinicians. As with many things, writing effective clinical patient notes is a matter of practice. For providers that have never before shared their notes with patients, it’s a process that takes some finesse and may require reworking phrasing to make the records more relatable. However, Fernandez notes that a practitioner needn’t view this as a burdensome endeavor; rather, they should think about the interpersonal skills they use in their in-person encounters to craft an open clinical note that’s clear and relatable.
