Effective Medical Note Writing

Core Quality Criteria

Medical notes should follow a problem-oriented approach that clearly identifies patient issues and how they should be managed and documented, as recommended by the American College of Physicians 1
Notes should be well-organized with appropriate structure to facilitate quick retrieval of relevant information, according to the American College of Physicians 2
The clinical record should include sufficient detail of the patient's story to effectively communicate the clinical situation, as suggested by the American College of Physicians 1
Notes should be an accurate but brief synthesis of history, findings, decision making, and plans, rather than a verbatim transcript of clinical interactions, as recommended by the American College of Physicians 3
Documentation should prioritize thoughtful review of previously documented clinical information to establish context, according to the American College of Physicians 4
Medical notes should avoid "note bloat" where key findings and actions are obscured by superfluous negative findings and irrelevant documentation, as suggested by the American College of Physicians 5

Copy-paste functionality, while potentially time-saving, presents significant risks for propagating factual errors when used improperly, as noted by the American College of Physicians 2
While templates and macros can improve completeness and efficiency, they must be used thoughtfully to avoid creating contradictory information or excessive documentation, according to the American College of Physicians 4
Electronic health records may lead to "copy/paste" issues where information is duplicated without appropriate editing, leading to outdated or inaccurate information, as suggested by the American College of Physicians 2

Effective and ongoing EHR documentation training should be provided to students, as recommended by the American College of Physicians 2

The primary purpose of clinical documentation should be to support patient care and improve clinical outcomes through enhanced communication, as suggested by the American College of Physicians 6
Notes should balance the need for comprehensive documentation with clarity and conciseness, according to the American College of Physicians 5
Professional standards regarding clinical documentation practices should guide student note development, as recommended by the American College of Physicians 6

Include pertinent positive and negative findings relevant to the patient's concerns, as recommended by the American College of Physicians, to effectively communicate the clinical situation 7
Use templates appropriately for standardized terminology to improve efficiency, as suggested by the American Medical Association, and include only clinically relevant positive and negative findings 8
Document pertinent findings related to the patient's concerns and chronic conditions, using a problem-oriented approach, as recommended by the American Academy of Family Physicians 7

For each patient issue, include current status and relevant findings, clinical reasoning and differential diagnosis, specific management plan, and patient education provided, as recommended by the American Heart Association 9
Use a problem-oriented format that clearly identifies each patient issue and includes clinical reasoning and differential diagnosis, as suggested by the American College of Physicians 10

Include the patient's perspective and experience in your documentation, and document your clinical thought process, including uncertainties and speculations, as recommended by the American Academy of Family Physicians 9
Document your clinical thought process, including uncertainties and speculations, and maintain the patient's voice in describing symptoms and concerns, as suggested by the American Medical Association 10

Avoid redundant documentation of the same content in multiple locations, as recommended by the American College of Physicians, to facilitate quick retrieval by future providers 11
Recognize that your note serves as a legal document that must be accurate and unaltered, and document to support appropriate billing levels, but prioritize clinical communication over coding requirements, as suggested by the American Medical Association 7