What information should be included in visit notes for patient encounters?

Essential Components of Visit Notes

Visit notes should document the patient's chief complaint, history of present illness, relevant patient history and evaluation, assessment, and plan—with particular emphasis on the Assessment and Plan sections, which clinicians identify as the most critical information for continuity of care. 1, 2

Core Documentation Elements

Patient Identification and Visit Context

• Patient identifiers: Include patient's name, date of birth, and unique identification number to verify identity 3
• Date and time: Document when the encounter occurred, including total encounter time for telephone visits 1
• Encounter type: Specify whether in-person, telehealth, or telephone consultation 1
• Name of caller: For telephone encounters, document who initiated the contact if not the patient 1

Chief Complaint and History of Present Illness (HPI)

• Chief complaint: The patient's primary concern that drives the visit 3
• HPI details: Onset, duration, severity, and progression of symptoms—this section is identified by clinicians as one of the two most important parts of the note 2
• Patient narrative: Include the patient's story in sufficient detail to accurately represent their experience 1
• Relevant context: For chronic conditions, document date of diagnosis and approximate date of onset when determinable 1

Past Medical History

• Chronic conditions: Document all chronic diseases including cardiovascular disease, renal disease, lung disease, diabetes, hepatitis, and malignancies 1, 3
• HIV-specific history (when applicable): Prior opportunistic infections, lowest CD4 count, highest viral load, and prior antiretroviral therapy with responses 1
• Prior complications: Any disease-specific complications that affect current management 1
• Immunization status: Document influenza, pneumococcal, hepatitis A/B, tetanus, and COVID-19 vaccination dates 1, 3
• Travel and exposure history: Geographic areas of residence and travel, particularly for endemic infections 1

Medications and Allergies

• Complete medication list: All prescription medications, over-the-counter drugs, supplements, vitamins, and herbal remedies 1
• Medication details: Dose, frequency, route, and whether dose titration is expected 1
• Prior antiretroviral history (when applicable): Previous regimens, duration, reasons for changes, adherence patterns, and resistance test results 1
• Allergy documentation: Specific hypersensitivity reactions including sulfonamides, NNRTIs, abacavir, and other drug classes 1
• Drug interactions: Active review at each encounter, including recent medication changes 1

Social History

• Substance use: Tobacco, alcohol, marijuana, cocaine, heroin, and other recreational drugs 1
• Social support: Family support systems and caregiver availability 1
• Financial barriers: Out-of-pocket medication expenses and ability to afford treatments 1
• Physical environment: Housing stability and environmental exposures 1

Assessment and Plan

• Assessment: Clinical evaluation of the presenting problem and relevant findings—identified by clinicians as the most important section alongside HPI 2
• Plan: Specific management steps including medications prescribed, tests ordered, referrals made, and follow-up timing 1
• Type of encounter: Document whether addressing a new problem, reviewing a chronic condition with management changes, interpreting test results, or coordinating care 1
• Disposition: Clear next steps and when patient should return or call 1
• Patient education: Document what written materials were provided and confirm patient understanding 1

Documentation Quality Considerations

What to Prioritize

• Place Assessment and Plan prominently: These sections are what clinicians reference first and most frequently 2
• Minimize Review of Systems detail: Clinicians largely judge ROS as superfluous unless it contains information not captured elsewhere 2
• Ensure accuracy: Patients identify inaccuracies as a major concern, particularly in heavily templated notes 4, 5
• Use clear language: Avoid excessive medical jargon when possible, as 29% of patients report notes contain too much technical terminology 4

Critical Pitfalls to Avoid

• Copy-paste errors: Avoid copying entire notes without editing, as this propagates factual errors, outdated information, and contradictory data 1
• Incomplete recording: Only 59% of information discussed verbally appears in medical records, with particular gaps in medical history beyond the present illness 6
• Assumption of absence: Clinicians often assume absence of documentation equals absence of disease—ensure positive and negative findings are explicitly documented 1
• Excessive length: 26% of patients report notes are too long; balance completeness with conciseness 4

Enhancing Patient Safety Through Documentation

• Enable patient review: Sharing notes with patients helps identify documentation errors that may undermine diagnostic accuracy 5
• Support follow-up: Clear documentation of recommended tests, results, and referrals helps avoid delays and missed diagnoses 5
• Medication reconciliation: Schedule time for patients to bring medication bottles to verify the documented list matches actual use 1
• Document patient-generated data: Include information from patient questionnaires, tracking devices, and patient messages while maintaining clear data provenance 1

Telephone Encounter Specifics

• Required elements: Date, time, patient name and DOB, caller name, reason for call, total encounter time, relevant history, assessment, plan, and disposition 1
• Complexity documentation: Specify encounter type (new problem, chronic problem review with management change, test interpretation, care coordination) to demonstrate expertise and decision-making complexity 1
• Billing compliance: Documentation must meet E/M visit requirements and demonstrate continuity of care 1