How to Write an Assessment Note
Assessment notes should follow a structured format that captures the patient's current clinical status, synthesizes findings from history and examination, and documents a prioritized treatment plan with specific goals and interventions. 1
Core Structure and Components
The assessment note should document:
Current clinical status: Include vital signs (heart rate, blood pressure, respiratory rate, temperature), relevant physical examination findings specific to the presenting condition, and any interval changes since the last visit 2
Synthesis of findings: Document how the subjective complaints, objective findings, and test results integrate to support your clinical impression 1
Problem list prioritization: List active problems in order of clinical significance, addressing both acute issues and chronic disease management 2
Essential Elements to Document
Patient-Specific Information
Symptom characteristics: Severity, type, spread, quality, and impact on daily functioning 2
Treatment response: Document efficacy of previous and ongoing treatments, medication compliance, and any side effects or intolerances 2
Functional status: Include disability assessment, use of assistive devices, and ability to perform valued activities 2
Psychosocial factors: Screen for depression, anxiety, sleep problems, and social determinants of health (food security, housing stability, transportation access) 2
Disease-Specific Assessment
For chronic conditions like diabetes, document:
Glycemic control: A1C results if not available within past 3 months, glucose monitoring data and patterns 2
Complication screening: Spot urinary albumin-to-creatinine ratio, serum creatinine with estimated glomerular filtration rate, comprehensive foot examination including monofilament testing 2
Cardiovascular risk: Lipid profile, blood pressure trends, assessment for atherosclerotic cardiovascular disease 2
For cardiac conditions, include:
Cardiovascular examination: Detailed cardiac and pulmonary findings, assessment of volume status, evaluation of post-procedure wound sites 2
Risk stratification: Document progression of disease, medication compliance, and quality of life assessment using standardized questionnaires 2
Treatment Plan Documentation
The plan should be goal-directed with measurable short-term (weeks to months) and long-term (years) objectives prioritized for risk reduction. 2, 1
Document:
Specific interventions: Detailed prescriptions including medication names, doses, routes, and timing; dietary modifications with specific targets; exercise prescriptions with frequency and intensity 2
Patient education provided: Document what was taught regarding disease management, medication use, and self-care strategies 2
Follow-up plan: Specify timing of next visit, which tests need repeating and when, and what symptoms should prompt earlier return 2
Communication: Note that the plan was actively communicated to the patient and primary healthcare provider 2, 1
Documentation Best Practices
Efficiency and Accuracy
Be complete but concise: Include all core clinical details without unnecessary verbosity 1, 3
Avoid excessive copy-forward: Do not propagate prior note content without editing, as this spreads errors and reduces clinical utility 1
Use dynamic data links: When available in electronic systems, link to data documented elsewhere (lab results, vital signs) rather than re-typing 4
Prioritize Assessment and Plan sections: These are the most frequently referenced sections and should contain the most clinically relevant information 5
Special Circumstances
For serious conditions or goals of care discussions:
Document prognosis: Include when discussing serious conditions or end-of-life planning 1
Record shared decision-making: Document discussions with patient and family, expressed wishes, unresolved issues, and recommendations from treating team and consultants 1
Common Pitfalls to Avoid
Omitting interval changes: Always document what has changed since the last visit, including new symptoms, medication adjustments, or test results 2
Incomplete medication documentation: Record not just current medications but also medication-taking behavior, rationing of medications, and any complementary/alternative medicine use 2
Missing functional assessment: Don't focus solely on disease metrics; document impact on daily activities, work, and quality of life 2
Inadequate risk factor documentation: For conditions like diabetes or cardiac disease, systematically address all modifiable risk factors including tobacco use, alcohol consumption, physical activity, and sleep behaviors 2