What is the difference between progress notes, consultation notes, and other types of notes in medical documentation?

Types of Medical Documentation Notes

Medical documentation includes several distinct note types, each serving a specific purpose: progress notes document ongoing patient care during hospitalization or follow-up visits, consultation notes capture specialist recommendations when another provider requests expert input, and additional note types include admission notes, discharge summaries, procedure notes, telephone encounter notes, and patient instruction documents. 1, 2

Progress Notes

Progress notes represent the most common form of clinical documentation, tracking the patient's clinical course over time during hospitalization or outpatient follow-up visits. 2

Key characteristics:

• Document using the SOAP format (Subjective, Objective, Assessment, Plan) to capture initial visits and monitor follow-up care effectively 2
• Include the patient's story in sufficient detail, capturing symptoms, concerns, and the patient's perspective 2
• Contain measurable clinical findings including vital signs, physical examination findings, and relevant test results 2
• Establish a treatment plan that prioritizes goals and outlines intervention strategies 2
• Should be complete, concise, and accurate to support information reuse across the care team 2

Common pitfall: Avoid excessive copy-forward of prior notes without editing, as this propagates errors and reduces clinical utility. 2 The American College of Physicians emphasizes that while EHR systems should support "write once, reuse many times," they must embed tags identifying the original source of information to maintain accuracy. 2

Consultation Notes

Consultation notes document when one provider requests expert input from another specialist regarding a specific clinical question or patient management issue. 1

Key characteristics:

• Contain the consulting provider's assessment of the specific clinical question posed
• Include recommendations for diagnosis, treatment, or management
• Communicate treatment and follow-up plans interactively with the primary healthcare provider 2
• Establish accountability for specialist input in the patient's care

Other Note Types

Admission Notes:

• Document the initial evaluation when a patient enters the hospital
• Include comprehensive history, physical examination, initial assessment, and treatment plan 3

Discharge Summaries:

• Synthesize the entire hospitalization
• Document hospital course, procedures performed, medications prescribed, and follow-up plans
• Critical for care transitions and communication with outpatient providers 3

Procedure Notes:

• Document specific procedures performed
• Include indication, technique, findings, and complications
• Essential for procedural accountability and billing 4

Telephone Encounter Notes:

• Capture patient-provider interactions occurring by phone
• Document clinical advice given and follow-up plans 1

Patient Instruction Documents:

• Provide written guidance to patients about their care
• Include medication instructions, activity restrictions, and warning signs 1

Documentation Metadata and Structure

All clinical notes contain essential metadata that establishes accountability and chronology: 1

• Author information establishes who created the documentation and responsibility for the documented information 1
• Authentication details indicate which healthcare provider verified the accuracy of the documentation 1
• Timestamps provide chronological records showing when encounters occurred and when documentation was completed 1
• Document status indicates whether the note has been completed or modified after initial creation 1

Special Documentation Circumstances

For do-not-attempt-resuscitation orders, progress notes must include:

• Prognosis documentation
• Description of discussions with family and medical team
• Documented expressed wishes of patient and family decision-makers
• Note of unresolved issues
• Recommendations from treating team and consultants 2

When documenting patient allegations:

• Use objective, factual language that preserves the patient's narrative without editorializing 5
• Include relevant context such as mental status and emotional state 5
• Avoid subjective interpretations about veracity; use direct quotes when possible 5
• Document when allegations are clinically relevant to patient care, safety assessment, or treatment planning 5

Electronic Health Record Considerations

The American College of Physicians emphasizes that structured formats facilitate data retrieval and analysis but may limit narrative elements providing context to patient care. 1 When using templates or structured formats, clinicians must ensure documentation accurately reflects the specific patient encounter rather than generic content. 1 The ability to access documents electronically supports care coordination among different providers and settings. 1