What are the key components and best practices for maintaining accurate and effective visit notes in patient care?

Key Components and Best Practices for Visit Notes

Primary Purpose and Core Principles

The primary purpose of clinical documentation is to support patient care and improve clinical outcomes through enhanced communication, not to satisfy billing or regulatory requirements. 1

Your visit notes should be:

• Problem-oriented with clear identification of each patient issue and corresponding management plans 2
• Brief but accurate syntheses of history, findings, decision-making, and plans—not verbatim transcripts 2
• Organized to facilitate quick retrieval of relevant information by future providers 2

Essential Content Requirements

What to Include

• The patient's story with sufficient detail to effectively communicate the clinical situation 1, 2
• Pertinent positive and negative findings relevant to the patient's concerns and chronic conditions 2
• Your clinical thought process, including uncertainties and differential diagnoses 2
• For each problem: current status, relevant findings, clinical reasoning, specific management plan, and patient education provided 2
• The patient's perspective and voice in describing symptoms 2

What to Avoid

• "Note bloat" where key findings are obscured by superfluous negative findings and irrelevant documentation 2
• Redundant documentation of the same content in multiple locations 2
• Excessive templated content that creates contradictory or generic information 1, 2

Technology Best Practices

Copy-Paste and Templates

While templates and macros can improve efficiency, they present significant risks for propagating factual errors and creating outdated information when used improperly. 2, 3

• Use templates only for standardized terminology sections 2
• Always edit copied content to reflect the current encounter accurately 3
• Tag or identify the original source when reusing information from prior entries 1

EHR-Specific Recommendations

• Allow patients to view data on screen during visits 1
• Explain what you are documenting and why the computer is present 1
• Maintain eye contact while typing or separate typing from patient interaction entirely 1
• Position the screen so patients can view their record as a shared space 1

Professional Standards and Organization

Chart Etiquette Principles

Each practice should develop consensus-driven professional standards emphasizing clarity, brevity, and attention to readers' needs, including patients. 1

• Place Assessment and Plan sections prominently since physicians refer to these first 4
• History of Present Illness and Assessment/Plan are the most critical sections 4
• Review of Systems should contain only clinically relevant information, not exhaustive negative findings 4

Documentation Workflow

• Thoughtfully review previously documented clinical information to establish context before adding new content 2
• Avoid redundant attestations—if you reviewed a lab result, the EHR should record this automatically rather than requiring you to document it separately 1
• Document to support appropriate billing levels, but prioritize clinical communication over coding requirements 2

Patient Access and Transparency

Patients should have access to visit notes through portals, as this improves patient satisfaction, trust, and safety without harming the patient-doctor relationship. 5, 6

• 84% of patients with portal access open their notes 6
• 77% report feeling more in control of their care 6
• 60-78% of patients taking medications report increased adherence after reading notes 6
• Only 1-8% report confusion, worry, or offense from reading notes 6
• Patients identify documentation errors in approximately 7% of cases, with 85% satisfied with error resolution 5

Common Patient Concerns

• Patients desire more detail rather than less, even if some content is confusing 7
• Medical jargon concerns 29% of patients, but most rely on providers to explain confusing content 7
• Heavily templated notes are more likely to contain perceived inaccuracies 7
• 26-36% have privacy concerns about open notes 6

Training and Implementation

Provide effective and ongoing EHR documentation training to all clinicians, including students. 2

• No single format is appropriate for all specialties, but each organization must establish standardized principles 1
• Cooperation among healthcare providers, systems, government, and insurers is needed to improve documentation 1
• Transform the medical record from a passive information repository to an active communication tool for the entire care team, including patients and families 1

Legal and Compliance Considerations

Your note serves as a legal document that must be accurate and unaltered. 2

• Maintain provenance of all data, including patient-generated information 1
• Ensure authentication information indicates which provider verified the documentation 3
• Include timestamps for chronological tracking of patient care 3
• Document status should indicate whether notes are completed or modified after initial creation 3