How do I create medical notes?

Creating Effective Medical Notes: Best Practices and Guidelines

The primary goal of medical documentation should be concise, history-rich notes that reflect the information gathered and are used to develop an impression, a diagnostic and/or treatment plan, and recommended follow-up. Technology should facilitate these goals efficiently without losing the humanistic elements that support ongoing patient-physician relationships 1.

Core Components of Medical Notes

Structure and Organization

• Follow a problem-oriented approach that clearly identifies patient issues and how they should be managed 2
• Organize notes with appropriate structure to facilitate quick retrieval of relevant information 1
• Include the patient's story with sufficient detail to effectively communicate the clinical situation 1
• Aim for an accurate but brief synthesis of history, findings, decision making, and plans, rather than a verbatim transcript 2

Essential Elements for Documentation

• Take a detailed history from the patient (and/or relatives) with specific reference to presenting symptoms, timeline, and progression 1
• Document vital signs, physical examination findings, and relevant test results 1
• Record all medications taken over the previous 2 months, including over-the-counter and complementary therapies 1
• Note previous medical problems and history of drug allergies 1
• Include time-based records with name, route, site, time, and dosage of administered medications 1

Documentation Best Practices

Avoiding Common Pitfalls

• Prevent "note bloat" where key findings and actions are obscured by superfluous negative findings and irrelevant documentation 1, 2
• Use copy/forward functionality cautiously, as it can propagate factual errors when used improperly 1
• Avoid copying and pasting entire notes, which can lead to outdated or inaccurate information 1
• Be cautious with templates and macros - while they improve efficiency, they must be used thoughtfully to avoid contradictory information 1

Improving Efficiency

• Optimize note templates by replacing free text elements with dynamic links that automatically populate with data from elsewhere in the EMR 3
• Consider using discrete data pick lists for common elements instead of free text 3
• Prioritize thoughtful review of previously documented clinical information to establish context 2
• Focus on sections most commonly reviewed by other clinicians - Chief Complaint in H&P notes and Assessment & Plan in progress notes 4

Types of Clinical Notes

History and Physical (H&P)

• Document chief complaint, history of present illness, past medical history, medications, allergies, family history, social history, review of systems, physical examination, assessment, and plan 4
• Include specific details about onset, duration, and progression of symptoms 1
• Record vital signs, including heart rate, blood pressure, respiratory rate, oxygen saturation, and temperature 1

Progress Notes

• Focus on changes in patient status, new findings, test results, and updates to the treatment plan 5
• Organize using a problem-oriented approach with clear categorization 5
• Document the patient's response to interventions 6

Discharge Summaries

• Include admission diagnosis, significant findings, procedures performed, treatment provided, patient's condition at discharge, and follow-up instructions 5
• Document medications at discharge with clear instructions 3
• Ensure continuity of care by clearly communicating the follow-up plan 6

Technology Considerations

Electronic Health Record (EHR) Use

• Balance structured data entry with narrative descriptions to maintain the patient's story 1
• Use EHR capabilities to review prior relevant information and establish context 1
• When pulling data from another location in the chart, indicate the source and supplement with appropriate narrative content 1
• Ensure documentation is legible, always available, and accessible by multiple authorized persons 1

Documentation Time Management

• Optimize templates to save time - studies show well-designed templates can save up to 23 minutes per patient encounter 3
• Focus on the most clinically relevant sections first - Assessment & Plan for progress notes and Chief Complaint for H&P notes 4
• Use appropriate documentation tools based on the type of note being created, as different notes have different optimal formats 5

By following these guidelines, medical documentation can fulfill its primary purpose of supporting patient care while meeting regulatory requirements and facilitating communication among healthcare providers.