Do you prepare medicine notes for a patient?

Medical Note Preparation for Patients

I do not personally prepare medical notes, but I can provide guidance on best practices for clinical documentation that healthcare providers should follow when creating patient medical records.

Core Documentation Principles

Medical notes should be problem-oriented, well-organized, and serve as an accurate but brief synthesis of history, findings, decision making, and plans—not a verbatim transcript of the clinical encounter. 1

Essential Components to Include

• Patient identification and contact information: Name, address, telephone number, and emergency contact details 2
• Current medications: Complete list with names, dosages, and frequency—this is critical as only 50% of doctors adequately document medications 3
• Allergy status: Must be clearly documented, as studies show only 68.8% of notes include this vital information 3
• Problem-oriented assessment: Each patient issue should include current status, relevant findings, clinical reasoning, differential diagnosis, specific management plan, and patient education provided 1
• Vital signs: Heart rate, blood pressure, respiratory rate, oxygen saturation, and temperature 2

What Makes Notes Effective

The History of Present Illness (HPI), Assessment, and Plan (A&P) sections are the most clinically valuable components and should be prioritized for clarity and completeness. 4 In contrast, Review of Systems is often viewed as superfluous unless it contains information not captured elsewhere. 4

Key quality markers include:

• Sufficient clinical detail to communicate the patient's story effectively 1
• Avoidance of "note bloat" where key findings are obscured by superfluous negative findings 1
• Thoughtful review of previously documented information to establish context 1
• Clear documentation of clinical reasoning, including uncertainties and differential diagnoses 1

Common Pitfalls to Avoid

Documentation Errors

• Typographical errors appear in 49% of medical notes and represent a modifiable area for improvement 5
• Copy-paste functionality presents significant risks for propagating factual errors when used improperly 1
• Medical jargon and acronyms appear in 96.7% and 99.1% of notes respectively, which can confuse patients who increasingly have access to their records 5
• Omission of provider identity: 3.9% of notes fail to include objective documentation of the clinician's identity 3

Template Misuse

Templates and macros can improve efficiency but must be used thoughtfully to avoid creating contradictory information or excessive documentation. 1 The key is including only clinically relevant positive and negative findings rather than auto-populating irrelevant data. 1

Patient Access Considerations

With the 21st Century Cures Act requiring patients have electronic access to all medical record information, documentation practices must adapt. 6 This means:

• Avoiding pejorative language in descriptions of patients, behaviors, and findings 2
• Increased clarity in documentation of care plans 2
• Timely completion of notes 2
• Maintaining accuracy while recognizing notes serve as legal documents 1

Research shows 74% of clinicians view open notes positively, with patients reporting increased engagement (74%), better medication adherence (60-78%), and feeling more in control of their care (59-77%). 6, 7

Transfer and Discharge Documentation

When patients transfer between facilities or are discharged, specific documentation is required:

A medical transfer summary must include: 2

• Current medication schedule and dosages
• Recent test results and diagnoses
• Scheduled treatment/appointments
• Contact information for the transferring facility
• Current health care issues including recent A1C values (for diabetic patients)

At discharge, provide patients with: 2

• Written summary of current health issues
• Medication list with doses
• Adequate medication supply until first post-discharge appointment
• Written information about drugs to avoid (if applicable)
• Community resource directory

Documentation During Procedures

For procedural sedation, the chart must contain time-based records including: 2

• Name, route, site, time, dosage/kilogram, and patient effect of administered drugs
• Level of consciousness and responsiveness
• Heart rate, blood pressure, respiratory rate, expired CO2, and oxygen saturation
• Adverse events and their treatment
• Discharge time and condition with predetermined discharge criteria met