In my previous post, I went over the essentials you should include in every note you write as a clinical clerk. Items such as date, time, identification, signatures and writing with dark colors, technique and legibly should always be enforced.
For Part 2, I’ll go over quickly how to write a note so it will be easily readable and useful to others reading it. These tips are easy to implement and it’s good for new clerks to build good habits early.
1. Be Organized
Whenever you start a note, you want to approach it in an organized matter. Whether it’s a progress note, a consult note or a dictation letter, make sure all the information is placed in its proper place. Your history of present illness should be together, your review of systems together, your physical exam together, lab results together and so on. Use whatever system makes sense for the situation. Often times, it means presenting things in a chronological order. Other times, you have to organize things according to symptoms or disease.
A good example would be to match your medical history and medications together. I often like to list my medical history in one column, and list the corresponding medications they take on the next column.
For progress notes, you may have heard of the S.O.A.P. format. S stands for subjective and is anything the patient tells you. O is for objective and is for what you observe, physical exam, lab values, imaging. A is for assessment and P is for plan. It’s an easy way to include everything and is universally used by most clinicians.
At first it’s hard to be organized, especially when there’s so much information to be processed. I would suggest printing off history template or using one of these scutsheets to help organize patient information when you write your notes.
2. Be Thorough
Make sure you go through the whole patient’s chart and relevant medical history. When you’re writing an admission history, you don’t want to miss out on easy to forget things like allergies, social history or code status. Always remember the vitals!
Ask the patient, ask their families, check their old charts and electronic records. Call their pharmacy or family doctor if you need to. Your notes should be as complete as they need to be.
If you’re doing a dictation, you want to make sure you include everything that was done for the patient. It might save their life one day if they’re found unconscious and unable to give a history, the medical record you leave behind will provide future health care givers to provide comprehensive care.
4. Be Detailed
The big picture matters, but it’s the little details that really set apart a note from a fantastic one. If you’re thorough you will pick up lots of new details that others often forget.
For example, if you were on the cardiology consult service, leaving a note describing a soft low-pitched diastolic rumbling at the apex would be much more helpful than murmur present.Even simple observations like the patient said “he could not tell where he was or what day it was” or he was up and walking around the unit gives a better sense of the patient’s health than lab numbers.
Small things count. If the patient’s creatinine was elevated at 150, even noting that the patient’s baseline was 120 for the last 2 months is attention to detail that will make you a better clinician and your documents more helpful to others when they read it.
4. Be Honest
Integrity matters. It’s easy to make up observations or lie about physical findings but the consequences can be dire. Write down only what you know is true. If it’s an observation, write down what YOU heard and saw.
It’s common that an incorrect comment becomes copied so many times by other people that it’s eventually assumed to be true. I remember one incident where an elderly gentleman had fallen down and was admitted to the emergency room. A initial assessment said he had significant bruising on both his legs. Subsequent reports by the emergency docs and admitting team also noted that. However, when our team finally saw that patient we did not think his legs were bruised at all. Turned out he had been wearing blue pants and some of that color had rubbed off on his legs. He actually had no bruises on his legs!
Do your best to be honest and correct. We will make mistakes and let things slip but you should never actively write down wrong facts. If you didn’t do that DRE, be honest and write not done or deferred for now. Better to be honest and reprimanded for not being thorough. Because if you are caught lying, everything else you’ve written is scrutinized.
5. Be Original
The most important part of any note is writing down what you think. For your assessment and impressions, people will be reading your note to see what you are thinking about the patient’s case. They want to know what you think is wrong and what you plan to do.
Apart from writing down your observations, you want to add value and something of use to your notes. If you’re writing a progress note, write down whether you think the patient has improved or declined, whether your diagnosis is correct and the treatment is working or if not, what’s on your differential and how are you going to investigate it.
6. Be Clear and Concise
Finally, remember notes are to be read and not just recorded. Whether it’s you reading your progress note 3 months later when a patient returns to clinic, or whether you’re sending a referral letter to a specialist, you want to be understood. Write legibly and write so your meaning gets across. Be concise and to the point. Don’t try to sound sophisticated or use fancy embellishments.
You would be surprised how much can be said when using the right choice of words. For example, if an ER referral note to a general surgeon that said “RLQ Pain, peritoneal signs, elevated WBC, CT suggestive of appendix” that would be all the surgeon would really need to book the patient for the OR. Of course, the surgeon would likely reassess the patient, but if original note was organized, thorough, detailed, honest and expressed why they though this was an appendicitis there is little need for repeating everything.
In this case a detailed and to the point note would have been highly useful. No one likes reading more than is necessary.
Write organized notes. Write thorough and detailed notes. Always be honest. Be original with your input. And above all, be clear and concise.
Please feel free to add any additional tips for writing good notes. If you have any tips you have found helpful, I would love to hear about them.