Note Writing

Chapter 11 Note Writing



Matthew J. Kapklein, MD, MPH


Medical records serve many purposes in day-to-day medical practice. They are chronologic logs of events during a hospital stay or series of office visits. They document medical thought process. They serve as a conduit of communication from one provider to another. They also often are examined by nonproviders for determining payment for services, gathering information for litigation, aiding in quality improvement, and myriad other reasons.



Medical Knowledge


For most medical documentation, not much medical knowledge is required. A notable exception is in the writing of assessments (including differential diagnoses) and plans. Clearly, differential diagnoses for any given problem require the ability to fit a set of data points into a recognizable pattern. A well-written differential diagnosis is prioritized in order of likelihood, specific to that patient and follows logically from the data you have presented.



Patient Care


The medical record serves as an aid to patient care by facilitating interprovider transfer of information. When you are writing your notes, it is useful to maintain the following mindset: “What information would another physician need to take care of this patient if I was unavailable?” The role of event notes, procedure notes, and course summaries in this approach is obvious. But in no area is this mindset more important than in writing the routine progress note.


Two formats for progress notes have gained popularity: SOAP and RICHMeN or systems-based. The SOAP format is familiar to most of us:


Subjective: A narrative description of any relevant events since the last entry, as well as any communications or concerns on the part of the patient

Objective: A listing of physical findings, laboratory values, and other measurable data

Assessment/Plan: A listing of the patient’s active problems (using the information listed above) and the plan for managing them

In the systems-based format, laboratory values, medications, and other data are categorized by organ system. It often follows this order:


Respiratory

Infectious/Immunologic

Cardiovascular

Hematologic

Metabolic/Nutritional

Neurologic

In this format, subjective material (recent events, patient complaints) and physical findings can go either before the “systems” or within them. After the systems are reviewed, an assessment and plan should follow. This format has the disadvantage that items may appropriately go in several systems, and some data do not seem to fit into any system. In addition, a rigid order of presentation may bury the most important information at the end. Finally, pieces of data must often be drawn from several “systems” in order to synthesize an assessment.


Despite its drawbacks, the systems-based format assists the note writer in remembering all relevant information to be transmitted in the note.

< div class='tao-gold-member'>

Related posts:

  1. The Special Needs Child
  2. Diarrhea (Case 6)
  3. Physical Abuse (Case 53)
  4. Intraventricular Hemorrhage (Case 37)

Stay updated, free articles. Join our Telegram channel
Tags:
Jul 18, 2016 | Posted by in PEDIATRICS | Comments Off on Note Writing

Full access? Get Clinical Tree
Get Clinical Tree app for offline access