What is the best written style for a physician's case sheet?

Best Practices for Physician's Case Sheet Documentation

The primary purpose of clinical documentation should be to support patient care and improve clinical outcomes through enhanced communication, with the patient's story included in as much detail as is required to retell the story. 1

Core Documentation Principles

Patient-Centered Documentation

• Include the patient's complete story with sufficient detail to accurately retell it 1
• Use specific, descriptive language when documenting findings, avoiding vague statements 2
• Maintain a consistent format with standardized terminology for detailed documentation 2
• Document factors that may worsen symptoms, unhelpful coping strategies, and steps for symptom management 2

Structure and Organization

• Use appropriate macros and templates to improve completeness and efficiency, particularly for standardized elements like review of systems and physical examination 1
• Capture structured data only where useful for care delivery or essential for quality assessment/reporting 1
• Maintain a problem-oriented approach that improves decision-making and treatment planning 1
• Include clear follow-up plans with specific timeframes and parameters for earlier follow-up 2

Electronic Health Record Best Practices

Room Setup and Patient Engagement

• Position the computer screen so the patient can view the record 1
• Maintain eye contact with the patient while typing 1
• Separate typing and patient interaction - use brief, short typing sessions focusing solely on the EHR 1
• When speaking to patients, stop typing and focus on the patient 1

Communication Techniques

• Talk to the patient while gazing at the computer using verbal and nonverbal backchannels (e.g., "ok," "I see," nodding) 1
• Use a postural style that allows facing the patient most of the time 1
• Invite the patient to look at the screen before they ask 1
• Inform the patient about the functions and role of the computer in their care 1
• Greet the patient and accompanying companions before beginning the computer interaction 1

Documentation Content Requirements

Essential Elements

• Patient identification information
• Date and time of encounter
• Chief complaint or reason for visit
• Relevant history (present illness, past medical history, family history, social history)
• Review of systems
• Physical examination findings
• Assessment/diagnosis
• Plan (including medications, tests, procedures, follow-up)
• Provider identification and authentication 1, 2

Special Considerations

• Document patient-learned information about their condition and helpful management strategies 2
• Include comprehensive medication lists with names, doses, and instructions 2
• Record lifestyle modifications and warning signs requiring immediate medical attention 2
• Document discussions about treatment options and shared decision-making 1

Common Pitfalls to Avoid

• Excessive copy/forwarding of information without proper review and editing 1
• Using judgmental language or subjective assessments 2
• Incomplete documentation of follow-up plans 2
• Excessive "note bloat" that obscures key findings and actions 1
• Prioritizing coding compliance over clarity and conciseness 1

Implementation Strategies

• Engage in ongoing EHR documentation training 1
• Review previously documented clinical information thoughtfully before incorporating it 1
• Consider providing printed instruction sheets to enhance patient understanding and compliance 3
• Maintain focus on the primary purpose of documentation: supporting patient care and improving outcomes 1

By following these guidelines, physicians can create case documentation that effectively communicates patient information, supports clinical decision-making, meets regulatory requirements, and ultimately improves patient care outcomes.