Clinical record keeping is an integral part of good professional practice and delivering quality healthcare. But as healthcare changes with new technology and reimbursement models, so should clinical documentation. Whether you’re a medical student, resident, or established physician with decades of experience, it can be helpful to go back to the basics. In this step-by-step guide to taking perfect clinical notes we will cover:
- Why write clinical notes
- The importance of context
- What to include in a clinical note
- Tips for better clinical documentation
- Basic legal considerations
- Open clinical notes
- How to keep documentation efficient
Please keep in mind: this guide is intended as a useful reminder and compilation of best practices. It is not legal or medical advice. When questions arise regarding clinical documentation, providers should always refer to their specialty-specific training and published legal guidelines.
Why write clinical notes
As a busy doctor, high-quality documentation can become a low priority. But remember that medical records are much more than an annoying task on your to-do list.
There are three fundamental reasons to strive for perfect clinical notes. First, the patient record is a form of communication. Good documentation informs future providers, including yourself, what happened and how you arrived at a treatment plan. It’s the most important way to facilitate high-quality patient care.
Second, the medical record is a legal document that could be heavily scrutinized in the case of malpractice. It is, therefore, crucial to document sensitive discussions regarding limits of care, prognosis, and treatment decisions.
Finally, clinical notes are a service document. Whether you are self-employed or work for a hospital, medical documentation supports reimbursement. Clear, complete, and accurately coded documentation translates into cost and revenue lines for the businesses you own or are employed by.
Whenever you change your documentation style or workflow, it’s helpful to remember why you write clinical notes in the first place. Consider how information you decide to include – or not include – affects the medical records’ efficacy as a form of communication, a legal document, and a document of service.
Getting the context right
Before getting into the content of a clinical note, remember to check the context. For example, are you writing in the correct patient chart? Have you included the date and time? Will the next person to read the note know who wrote it?
These questions are so basic they are easy to overlook. However, small context errors lead to enormous time lost and negative impacts on patient health. Before starting your note, make sure to check the following:
- Patient name – Does the name on the chart match the patient you’re documenting for? This is especially important in a digital context, where it can be easy to click the wrong button or open the wrong window.
- Date/time – Did you include the correct date and time of your encounter? Time is especially important in emergency or ICU settings, but can also be easy to miss if you are catching up on clinical notes at the end of the day.
- Heading – Include a descriptive heading if the note could be edited by multiple providers. For example, “Surgery progress note” gives important context if you’re in a hospital or multi-disciplinary outpatient setting.
- Signature – Make sure to clearly sign every entry with your name and title.
What to include in a perfect clinical note
Start by briefly summarizing the main presenting issues. For example, “81-year-old male presenting with pneumonia.” Then use the SOAP method to write your note in a clear and consistent manner.
SOAP stands for Subjective, Objective, Assessment, and Plan. It’s a useful acronym for remembering the main elements of any clinical note.
Subjective – This section describes the patient’s story as you understand it. Providers typically use a narrative form to describe the patient’s chief complaints, including onset, chronology, quality, and severity. Document what the patient tells you about how they’re feeling and what happened, in their own words, using direct quotations as appropriate.
Objective – Here you should document the measurable or objective facts about the patient’s status. This could include how you observe the patient (“Patient appears pale and in discomfort…”), vital signs, or other findings from your physical examination (“Widespread expiratory wheeze on auscultation of the chest…”), and any relevant laboratory results.
Assessment – This is your primary medical diagnosis or an interpretation of what “S” and “O” mean. If a diagnosis has already been made, comment on whether the patient is clinically improving or deteriorating. For hospitalized patients, the assessment should summarize a complete list of diagnoses every 1-2 days.
Plan – Document a clear treatment plan, meaning what happened as a result of you seeing the patient. This should include further investigations, referrals procedures, and any new medications or other prescribed therapies.
Tips for better clinical documentation
Every physician has encountered the SOAP method, which gives a basic format. But structuring your documentation this way doesn’t guarantee a perfect clinical note.
Here are some additional tips for excellent clinical documentation:
- Make entries as soon as possible after providing care. Prompt documentation reduces the risk of forgetting key details. It also ensures other team members are aware of any changes to the patient’s condition or management plan. While this isn’t always possible in reality, do the best you can. If you find you’re consistently completing clinical notes long after patient visits, talk with your colleagues about how you might improve your documentation workflow.
- Be thorough. Remember that the core purpose behind documentation is communication. Future readers may not have the context you have, so make sure to include all the important details as clearly as possible.
- Be brief. Brevity isn’t just about getting through your documentation efficiently, it also helps your care team. Other providers need your note to quickly communicate important information with as little extraneous detail as possible.
- Be clear. Avoid using abbreviations or ambiguous terms. If you alter or revise a clinical note, remove information using a strikethrough and sign/date your correction.
Basic legal considerations
There are strict laws that govern the handling and content of clinical records, whether you’re in the United States or another country. In general, these exist to support three aims: 1) accuracy and legibility of clinical records content; 2) confidentiality and data protection; 3) patient access to medical records. The following reminders are summarized from published research, but always make sure you know relevant legal requirements for your context.
Accuracy and legibility of clinical records content
From a legal perspective, there are a few elements to make sure you include in a clinical note. The first is relevant clinical findings, meaning your professional diagnosis as well as evidence to support your plan. You also want to include a record of decisions made and actions agreed on, as well as who made the decisions and agreed to the actions. Finally, record the plan and any other information given to the patient. Remember that from a legal perspective, if something isn’t recorded in the clinical notes then it didn’t happen.
Confidentiality and data protection
In the digital era, confidentiality means that you don’t share patient information without consent and that your entire care team takes necessary steps to protect patient data.
Rules vary by country, but practitioners in the United States will want to review the HIPAA Privacy Rule. Work with your care team to ensure you’re taking the necessary steps to protect patient data and address potential health IT security risks. The Office of the National Coordinator for Health Information has a helpful seven-step approach for implementing a security management process.
Patient access to medical records
Patients have a right to access their medical records, and laws are changing to protect this right more fully. In the U.S., a new federal privacy rule gave patients access to clinical notes starting in April 2021. That means that clinicians and hospitals are required to give patients easy access to their health information, including notes and test results, in a fully automated, low-cost manner. As we discuss below, this legal requirement means that “perfect clinical notes” may look different today than they did in the past.
Open clinical notes
In 2021 an ONC Cures Rule went into effect, requiring that all hospitals and clinicians in the U.S. make full clinical notes easily available to patients. For some providers, this patient rights win won’t change anything because many healthcare organizations had already adopted an ‘open notes’ policy. In fact, prior to the Cures Rule, 250 healthcare organizations already offered open notes to more than 50 million patients registered on their portals.
However, with open notes now the norm, some providers may want to adjust the content or tone of their notes. In an article titled “Your Patient Is Reading Your Note” published in The American Journal of Medicine, the authors suggest 7 tips for implementing open notes in clinical practice:
- Be clear and succinct
- Directly and respectfully address concerns
- Use supportive language
- Include patients in the note-writing process
- Encourage patients to read their notes
- Ask for and use feedback
- Be familiar with how to amend notes
You can find a compilation of tips and examples for those suggestions here.
How to keep documentation efficient
We would be remiss not to emphasize that perfect clinical notes are the ones you get done efficiently. At a time when most physicians spend over 15 hours each week on clinical documentation and other paperwork, physician burnout is a serious risk.
1. Leverage the skills of your team members
You don’t have to document everything yourself. Strategically involve other team members to make sure everyone’s time is being used wisely.
2. Complete most documentation in the room
Many providers have found that dictating clinical notes during patient visits saves time and provides ancillary benefits. For example, when talking with a patient about their health history or treatment plan, summarizing aloud can double as your dictation and a way to engage the patient, improve understanding, and ensure accuracy. Whether you dictate or type, consider completing most documentation in the exam room.
3. Know the E/M documentation guidelines
Save time by adhering to the guidelines and documenting only what’s medically necessary to complete today’s visit. For example, a 99213 level of service, which is the code used 61 percent of the time by family physicians seeing Medicare patients, does not require a comprehensive review of systems or a comprehensive exam.
4. Use basic EHR functions
Templates, for example, are helpful for routine visits where clinical queries are standard. In complex or changing situations, manual typing – or mobile dictation – may be the fastest option. But if it’s flu season save yourself time by creating a basic influenza vaccine template. See more tips on how to optimize your EHR workflow.
5. Perfect clinical notes won’t be perfect
The EHR can be a black hole for perfectionists and compulsive “box-checkers.” Know what matters and leave the rest alone. Not all boxes need checking and not all categories need filling on every visit.
6. Forget the “opus”
Remember that the clinical note is not a biography. In the plan section of the note, be clear and concise including only what’s necessary so that the next person who sees your note will be able to understand your reasoning.
7. Time yourself
Use a timer and see how long it takes you to complete a note. Using this baseline, set a goal to decrease the time it takes you to write each patient note.
Remember that excellent clinical documentation is the result of initial training and continuing education. As healthcare changes, how you document will change too. Periodically take time to review your documentation and EHR workflow and make adjustments as necessary.
At the end of the day, perfect clinical notes are notes that meet basic clinical and legal requirements and fit within your clinical workflow.