What should be included in visit notes for a patient?

Essential Components of Visit Notes

Visit notes must document the patient's clinical course, treatment plan, and follow-up instructions to ensure continuity of care, proper reimbursement, and legal protection. 1

Core Documentation Elements

Patient Identification and Visit Context

• Document the visit type (scheduled vs. unscheduled) and mode (office, telephone, home visit) at the time of the encounter 2
• Record the provider type using standardized codes (e.g., physician, nurse practitioner, physician assistant) to ensure accurate reimbursement 1
• Include date, time, and reason for visit 3

Clinical Assessment Components

History Documentation:

• Time of symptom onset and potential triggers 2
• Severity of current symptoms compared to previous episodes 2
• Response to any treatments given before the visit 2
• All current medications with timing of last dose 2
• Number of previous unscheduled visits, ED visits, and hospitalizations within the past year 2
• Previous episodes of serious complications (e.g., loss of consciousness, intubation) 2
• Comorbid conditions that may complicate management 2

Physical Examination Findings:

• Level of alertness and overall patient status 2
• Vital signs and relevant objective findings 2
• Disease-specific markers (e.g., respiratory distress, wheezing, edema) 2

Assessment and Diagnosis:

• Use ICD codes to document all diagnoses, distinguishing primary from secondary diagnoses 1
• Document the severity classification of the condition 2
• Note any complications identified (e.g., pneumonia, pneumothorax) 2

Treatment Plan Documentation

Medications:

• Create a complete medication list including prescription drugs, over-the-counter medications, and supplements 2
• Document medication name, dose, frequency, route, and reason for each medication 2
• Note whether dose titration is expected over time 2
• Record any medication changes or discontinuations 2
• Document all systemic corticosteroid prescriptions for exacerbations, including those prescribed for later use with self-management plans 2

Procedures:

• Use procedure codes to document all interventions performed during the visit for proper reimbursement and resource tracking 1

Follow-up Instructions:

• Specific follow-up appointments scheduled 1
• Tests or referrals ordered with expected timelines 4
• Warning signs requiring immediate medical attention 2
• Self-management instructions 2

Patient-Centered Elements

Patient Goals and Concerns:

• What the patient most wants to accomplish at the visit 2
• What worries the patient most about their condition 2
• What the patient wants to be able to do that they currently cannot 2
• Patient expectations from treatment 2

Environmental and Social Factors:

• Environmental exposures that worsen the condition 2
• Barriers to medication adherence (cost, access) 2
• Transportation challenges for follow-up visits 2
• Social support systems 2

Documentation Quality Standards

Accuracy and Clarity

• Ensure prescriptions are legible with patient name, date, and physician signature 3
• Date all documentation to prevent misuse and establish timeline 3
• Avoid excessive templating that captures coded data at the expense of narrative information 1
• Document in simple language that patients can understand when notes are shared 2

Legal and Reimbursement Considerations

• Proper documentation is the only way to prove treatment was carried out appropriately in negligence cases 3
• Poor records mean poor defense; no records mean no defense 3
• Include consent forms for procedures 3
• Document nursing care, laboratory data, and diagnostic evaluations 3

Common Pitfalls to Avoid

• Avoid undated prescriptions that patients could misuse 3
• Do not rely solely on templated Review of Systems sections, which physicians often find superfluous unless they contain information missing from other sections 5
• Avoid documentation inaccuracies, particularly in heavily templated notes that patients may identify when reviewing their records 6
• Do not omit follow-up plans for test results and referrals, as this can lead to delays and missed diagnoses 4

Optimal Note Structure

Place Assessment and Plan at the beginning rather than the end of the note, as these are the sections physicians refer to first and reviewing from top to bottom may cause cognitive load 5. The History of Present Illness, Assessment, and Plan are consistently identified as the most important sections by both physicians and patients 7, 5.