Clinic notes serve a number of roles. They are a record for future clincial encounters, serve as a legal document for potential medico-legal issues, and can also help guide the clinical encounter through the use of templates.
Clinical notation, or charting, can be done in a number of ways. Many health care providers use free hand. Others use pre-prepared templates. Charting has traditionally been done on paper, though an increasing number use an electronic medical record, or EMR. Others use dictation to generate a typed clinic note.
Different health care providers chart at different times. At the very least it is important to record soon after the encounter, and at most at the end of the day. Some people generate the clinic note during the encounter, either on paper or the computer. Others take simple notes as they meet with the patient and rearrange their thoughts afterwards. It is imperative to work with speed and efficiency, while maintaining completeness.
Shorthand or abbreviations can be helpful to save space and time. However, ensure that you and others will be able to understand the note in the months or years down the road.
Always ensure the patient's name, date of birth, your name, and the date are included at the top of the note.
There are a number of formats that are possible to use while charting, and the type of clinical encounter will often determine the type of note that is recorded. One of the most common is a SOAP note, which will be described here. SOAP stands for:
Subjective: the patient's symptoms - what they have noticed or experienced.
Objective: relevant findings on the clinical exam; recent labs or imaging results
Assessment: overall sense of status, be it a new diagnosis or changing clincial status. A problem list may be helpful here.
Plan: the way forward, addressing each of the problems.
30 November 2011
GP, female, DOB 15 December 1997
S: Three day history of jaw pain, left ear pain, and left eye discharge.
No fever, chills, nausea, vomiting, diarrhea. No recent illness, no recent antibiotics.
Close contact with another child with similar symptoms 1 week ago.
O: Afebrile. Vitals normal.
Visual acuity 20/20 right, 20/60 left, uncorrected.
Large tonsils with exudate, left tympanic membrane cloudy, no sinus tenderness.
Pus-like discharge from left eye. No dental pain, no pain with jaw movement.
Eye movements normal, non-painful.
A: Otitis media with possible bacterial conjunctivitis.
Swabs of eye and tonsils taken for culture and sensitivity.
P: Amoxicillin 40mg/kg divided TID, erythromycin 0.5% ointment to eyes.
Follow-up arranged with opthalmology in 24 hours.
To return to emergency department if symptoms worsen in the next 24 hours.
Organizing your note into the SOAP format can be formal, including each individual heading, or can be less formal, where you describe the findings in point form.
Some people combine Assessment and Plan under one heading, summarize the situation in 1-2 lines, and then list problems and plans alongside each other.
The important things are that you have a history and physical exam, and that your impression and plan are supported by your findings.
Another important component of the clinic note is follow-up. Ask yourself, does the patient know when to come back? What to do if treatment is ineffective?
Planning for followup provides the patient with guidelines for returning, and provides you with the opportunity to counsel the patient on course of illness.