What should a patient encounter note include?

Essential Components of a Patient Encounter Note

A comprehensive patient encounter note should include structured documentation with clear sections for subjective information, objective findings, assessment, and plan, while maintaining patient-centered language and ensuring all relevant clinical data is accurately captured to support continuity of care.

Core Structure: SOAP Format

The SOAP (Subjective, Objective, Assessment, Plan) format provides the foundation for effective clinical documentation:

1. Subjective Section

• Chief complaint/reason for visit - Document in patient's own words 1
• History of present illness (HPI) - Include onset, duration, severity, and chronology 2, 3
• Past medical history - Document prior HIV-associated complications, comorbidities, opportunistic infections, malignancies, and cardiovascular disease history 2
• Medication history - List all current medications including:
  • Prescription drugs
  • Over-the-counter medications
  • Dietary/herbal supplements
  • Allergies and previous hypersensitivity reactions 2
• Social history - Document:
  • Tobacco, alcohol, and recreational drug use
  • Occupational exposures
  • Living situation and support systems 2
• Family history - Document relevant hereditary conditions 2

2. Objective Section

• Vital signs - Include temperature, pulse, respiratory rate, blood pressure, oxygen saturation 2
• Physical examination findings - Document relevant positive and negative findings using specific, descriptive language 1
• Laboratory and diagnostic test results - Include significant findings and reference ranges 2, 1
• Review of systems - Document pertinent positive and negative findings 3

3. Assessment Section

• Diagnosis/differential diagnosis - List primary diagnosis and other potential diagnoses 2, 3
• Clinical reasoning - Document thought process and interpretation of findings 1
• Risk assessment - Include risk factors for poor outcomes when relevant 2

4. Plan Section

• Treatment plan - Document specific interventions, medications with dosages, and duration 1
• Patient education - Record information provided to patient 4
• Follow-up instructions - Include specific timeframe and parameters for earlier follow-up 1
• Referrals - Document any specialist consultations requested 2

Documentation Best Practices

Electronic Health Record Considerations

• Use templates and macros appropriately to improve completeness and efficiency 1
• Maintain consistent format with standardized terminology 1
• Avoid copy-paste errors that perpetuate outdated information 1
• Document in real-time when possible to maintain accuracy 2

Patient Safety Elements

• Medication reconciliation - Document complete medication review 2
• Allergy verification - Confirm and document all allergies and reactions 2
• Patient identification - Use two patient identifiers (name, date of birth) 2
• Critical follow-up items - Highlight important tests or referrals requiring follow-up 1

Patient-Centered Documentation

• Use non-judgmental language that respects patient dignity 1
• Document patient preferences and goals of care 5
• Include patient understanding of their condition and treatment plan 4
• Record shared decision-making discussions 1

Special Documentation Considerations

Telephone/Virtual Encounters

• Document date and time of the call/encounter
• Include name of caller if not the patient
• Record total encounter time
• Document assessment and plan as with in-person visits 1

High-Risk Situations

• Refusal of recommended care - Document discussion of risks, benefits, and alternatives 1
• Leaving against medical advice - Record patient's symptoms, condition, test results, and discussions about completing evaluation 1
• Handoffs - Document key information transferred to receiving provider 2

Documentation Pitfalls to Avoid

• Incomplete documentation of patient education and follow-up plans 1
• Judgmental or stigmatizing language 1
• Vague statements about negative findings 1
• Excessive use of copy-paste functionality 2
• Failure to document medication changes or reconciliation 2
• Missing documentation of patient understanding and consent 4

By following these guidelines, healthcare providers can create patient encounter notes that effectively communicate clinical information, support continuity of care, meet legal and regulatory requirements, and remain patient-centered.