Writing an Effective Patient Note with Documentation Guidelines

A patient note is the primary communication tool to other clinicians treating the patient, and a statement of the quality of care. EHRs aim to assist you in writing a patient note, but in the end, the note comes from you, the physician or caregiver, not from the EHR. Your EHR can help you write a better note, but it can also make a note more difficult to read. By following some documentation guidelines, you can write a strong and concise note, no matter what EHR you use.

When approaching notes, ensure you follow the two acceptable formats, SOAP (subjective, objective, assessment and plan) or APSO (assessment, plan, subjective, objective). There are two suggested steps to document an effective and informative note, and four sections (SOAP or APSO) that you will want to include in a patient note.

• Step one is to review the relevant medical history including any previous notes for the patient so that the patient’s status is fully understood.
• Step two is to verify that the patient has adhered to the previous treatment plan—taking prescribed medications, completed diagnostic testing, primary and referral visits, adhering to diets, etc.

Crafting an Effective Patient Note

After these steps are completed, you can start your effective and informative note, keeping in mind that the note should be as concise as possible. We’ll follow SOAP for our example.

Subjective

In the subjective section (S), start the note by identifying previous notes that were reviewed by referencing the past notes into the current note. Most EHRs allow you to copy and paste previous notes, all lab results, radiology reports and other sections of the chart into your note. However, copying and pasting previous notes should be avoided given the risks of inclusion of irrelevant or inaccurate information as well as the risk of excessively long notes (also referred to as note bloat). Ensure the documentation of the patient’s chief complaint(s) and any new problems are clearly stated. Also, document the patient’s degree of adherence to the treatment plans from the previous visits.

Objective

The section that follows should be objective (O), documenting the physical exam associated with the chief complaint(s) and any new problems. Be sure to highlight any changes in the examination, document any relevant diagnostic testing (i.e., laboratory, radiology, pathology) associated with the chief complaint(s) and any new problems.

If any other items on the problem list complicate the current chief complaint(s) and any new problems, then include those problems and how/why they contribute to the current chief complaints and/or new problems.

Ensure you avoid note bloat by taking the following steps:

• Only include medications that are being used to treat the chief complaint(s) and new problems, the entire medication list is not necessary.
• If the visit is not for the treatment of allergies or an allergic reaction, do not include the patient’s allergies into the note.
• Items on the problem list that do not impact current treatment should not be brought into the note.

Assessment

The third section will be the assessment (A). Document the differential diagnosis based upon the information recorded in the subjective and objective areas of the note.

Plan

You will conclude with the fourth section—the treatment plan (P). In this section, document any continuing and new plan(s) and the thought process behind it. This includes any diagnostic or therapeutic procedures performed during the encounter or to be ordered after the visit, medications prescribed, etc. Document any changes to existing treatment plan(s) and the thought process behind the treatment plan(s).

Final Step

The final step is to review the note prior to signing and make sure it reads clearly and is straightforward. The note is your tool to communicate with yourself on future visits and other providers who may care for the patient.

Most importantly when you’re writing patient notes: keep your audience in mind, that’s the other members of the patient’s care team, and in many cases the patient themselves. Documentation burden affects not only the writer of the note, but also the readers. So think of the famous saying attributed to Blaise Pascal and many others: “I’m sorry to write you this long note, I didn’t have time to write a short note.” Take the time, avoid the EHR’s note-bloat temptations, and keep it short and concise.

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