What should be included in patient care notes?

Essential Components of Patient Care Notes

Patient care notes should include structured documentation with clear sections for subjective information, objective findings, assessment, and plan, using standardized terminology while maintaining clarity and brevity to ensure effective communication among healthcare providers.

Core Structure of Patient Care Notes

SOAP Format

The American Academy of Family Physicians recommends organizing patient care notes using the SOAP format 1:

• Subjective: Patient's story, symptoms, concerns, and history
• Objective: Physical examination findings, vital signs, laboratory results, and diagnostic test results
• Assessment: Clinical impression, differential diagnoses, and interpretation of findings
• Plan: Treatment plan, follow-up instructions, and patient education

Documentation Standards

The American College of Physicians emphasizes that documentation should 2, 1:

• Use specific, descriptive language rather than vague statements
• Maintain consistent format with standardized terminology
• Be clear, brief, and attentive to the needs of other readers, including patients
• Include only clinically relevant information

Essential Content Elements

Patient Information

• Complete demographic information
• Chief complaint or reason for visit
• Relevant medical, surgical, and social history
• Current medications and allergies
• Review of systems relevant to the presenting problem

Clinical Data

• Vital signs with quantitative measurements 1
• Physical examination findings with specific descriptions 1
• Laboratory and diagnostic test results with interpretation 2
• Patient's response to treatments or interventions

Assessment and Plan

• Clear diagnostic impression or differential diagnoses 1
• Treatment plan with specific medications, dosages, and frequencies
• Patient education provided, including disease-specific information 1
• Follow-up instructions with specific timeframes 1
• Parameters for earlier follow-up (e.g., "return if experiencing X symptoms") 1

Special Documentation Considerations

Procedural Documentation

For procedures such as endoscopy, documentation should include 2:

• Pre-procedure assessment and informed consent
• Intraprocedural monitoring (vital signs, medication administration)
• Recovery assessment using standardized criteria (e.g., Aldrete scoring system)
• Discharge instructions and follow-up plan

Patient Transfers and Transitions of Care

When transferring patients between facilities, documentation should include 2:

• Current medication schedule and dosages
• Recent test results and appointments
• Contact information for the transferring provider
• Specific follow-up needs

Advanced Care Planning

For patients with serious conditions, documentation should include 2:

• Goals of care discussions
• Identification of substitute decision-makers
• Patient preferences regarding interventions
• Documentation of advance directives when applicable

Documentation Best Practices

Clarity and Organization

• Use quantitative measurements when possible 1
• Organize information with clear headings 1
• Avoid medical jargon that patients may not understand 3
• Document in chronological order to maintain narrative flow

Accuracy and Completeness

• Document all patient interactions, including phone calls and electronic communications
• Record time-based information for medication administration 2
• Document patient education and understanding of instructions 1
• Note any patient concerns or questions

Electronic Documentation Considerations

• Use templates judiciously - avoid over-reliance that may lead to inaccuracies 3
• Ensure that auto-populated data is reviewed for accuracy 4
• When copying forward information, clearly indicate the source and verify current accuracy 2
• Consider that patients may access notes through patient portals 3, 5

Common Pitfalls to Avoid

• Incomplete documentation of follow-up plans 1
• Using judgmental or stigmatizing language 1
• Excessive copying and pasting without verification
• Overuse of templates without personalization 3
• Documentation that focuses on billing requirements rather than clinical care 2
• Missing documentation of patient education or understanding

Quality Improvement Considerations

• Implement standardized forms to improve compliance with documentation standards 2
• Regularly review documentation practices as part of quality assurance 2
• Use dynamic links and discrete data pick lists to reduce documentation time 4
• Incorporate patient feedback to improve note quality and readability 3

By following these guidelines, healthcare providers can create patient care notes that effectively communicate clinical information, support continuity of care, and meet regulatory requirements while remaining focused on patient-centered care.