How to Present Cases and Write Clinical Documentation
Focus on creating concise, problem-oriented notes that tell the patient's story with clear clinical reasoning, avoiding excessive copy-paste and irrelevant details that obscure key findings. 1
Core Structure for Clinical Documentation
Use a problem-oriented approach that clearly identifies each patient issue and documents how it should be managed 2, 1. Your note should be an accurate but brief synthesis—not a verbatim transcript of the clinical interaction 1.
Essential Components to Include:
For History Documentation:
- Patient's story in their own words describing symptoms and concerns 1, 3
- Pertinent positive findings directly relevant to the patient's concerns 1
- Pertinent negative findings that help narrow your differential diagnosis 1
- Relevant past medical history related to current problems 1
- Current medications that may impact the presenting issue 4
For Each Problem in Your Assessment/Plan:
- Current status with relevant findings 1
- Your clinical reasoning and differential diagnosis 1
- Specific management plan with clear next steps 1
- Patient education you provided 1
Critical Pitfalls to Avoid
Avoid "note bloat" where key findings get buried in superfluous negative findings, irrelevant documentation, and excessive differential diagnoses 2, 1. This makes records difficult and time-consuming for others to read 2.
Do not copy-paste entire sections without editing, as this propagates factual errors and creates outdated or inaccurate information 1. When you do review and carry forward prior information, ensure it remains accurate and adds value 2.
Never document redundant content in multiple locations—this wastes time for future providers trying to find relevant information 1.
Practical Approach to Case Presentation
Start with the patient's perspective: What brought them in, using some of their actual words 1, 3. This identifies important information and facilitates empathy in all caregivers who read your note 3.
Organize chronologically but focus on relevance: Include sufficient detail to retell the story effectively, but prioritize information that influenced your diagnostic and treatment decisions 2, 1.
Document your clinical thought process explicitly, including uncertainties and your reasoning for why you pursued or excluded certain diagnoses 1. This demonstrates your cognitive work and helps others understand your decision-making 5.
Using Templates and Technology Appropriately
Templates can improve efficiency for standardized sections like review of systems and physical examination findings 2, 1. However, they must be used thoughtfully to avoid creating contradictory information or excessive documentation 1.
When reviewing prior documentation, thoughtfully edit what you carry forward rather than blindly copying 2. Establish context by reviewing longitudinal history and care plans, but only include what remains accurate and adds value 2.
Communication Skills for History-Taking
Practice active listening and empathetic communication when gathering information from patients 6. This facilitates patient participation and autonomy in their care 6.
Ask specifically about:
- Presenting symptoms and their characteristics 4
- Related symptoms that may have been missed 4
- Complete medication list 4
- Smoking, alcohol, and recreational drug use 4
- What the patient understands and feels about their situation 3
Primary care physicians often miss 41% of essential history items in initial encounters, frequently overlooking related symptoms and complete medical history despite asking about presenting complaints 4. Being systematic prevents these gaps 4.
Training and Improvement
Seek ongoing EHR documentation training as an essential part of professional development 2, 1. Documentation skills require continuous refinement, not just initial instruction 2.
Remember the primary purpose: Your note should facilitate seamless patient care and improve outcomes through enhanced communication 1. Every element you include should serve this goal 2.