Organizing clinical patient notes is one of the most critical tasks for any healthcare practitioner. It helps to optimize productivity while ensuring the quality of documentation is maintained.

However, ensuring that the correct information is recorded can be a challenge. Below are some tips to help you get the job done.

Sort by Date

Medical notes are essential to healthcare, providing a paper trail legally required by law. They are the best way to communicate important details and ensure that future providers will have access to the information they need.

It can be easy to get tangled up in the minutiae of clinical notes, so it’s critical to know how to write clinical patient notes by keeping them simple and organized. This can help ensure patients get the necessary care while saving them time.

Organizing your clinical patient notes by date is one of the best ways to achieve this goal. For instance, it’s often helpful to sort your records by the date of the first visit to the patient, so you can be sure that any changes or additions made to their care plan are updated promptly.

This tip is essential for working in an emergency setting or seeing patients experiencing acute illnesses. In these cases, prompt documentation is crucial to ensure that other team members are aware of any updates to their care plan.

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The perfect clinical note clearly, and concisely describes the patient’s condition, including all relevant information. This consists of the patient’s onset, complaints, severity, quality, and chronology; your decisions and actions are taken to date; the plan you agreed on; and any other information given to the patient that is relevant to their care.

Ideally, the note is written as soon as possible after the patient’s visit. This helps you remember the details of the visit and ensures that other team members can access this vital information and follow up as necessary.

This section documents the measurable facts of the patient’s condition, such as vital signs (blood pressure, weight, etc.), a physical exam, laboratory results, and imaging results. It is usually the most exciting part of the note and should be written as a chart. It is most likely found on a future patient’s medical record. It is also one of the most challenging sections to write. However, it is also one of the most rewarding and can be a great way to connect with your patients on an emotional level.

Sort by Author

When reviewing your notes, you can use the Sort by Author feature to quickly filter the notes only to show those written by a specific clinician. This option is handy if you are a nurse and want to quickly review the messages of the nurse who looked after your patient that morning or if you are an assistant and need to see the notes of a particular medical student or resident to be prepared for their shift.

As you prepare your notes, you must ensure that you are writing them in the correct patient chart and have included the date and time of your encounter. These details will help the person reading your note understand the context of what you are writing about.

Duplication of text is well-documented in clinical records, leading to wasted clinician time, medical errors, and burnout. This study aims to determine the prevalence and scope of duplication behavior in routinely generated clinical notes and identify the factors associated with this practice.

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When writing clinical notes, ensure they’re organized and tell a continuous story about the patient. This will help your team members follow your care plan and avoid confusion later.

In addition, ensure the note is readable with an appropriate font, legible handwriting, correct spelling, and few or no abbreviations. A message that doesn’t have these components can be challenging to read, so take the time to write clearly and consistently.

If you have much information to convey, use a template like SOAP to separate your data into four categories (Subjective, Objective, Assessment, and Plan). This will allow you to quickly find the necessary information without returning to the record’s beginning.

Duplication of text is a significant problem for clinicians, making it difficult to find relevant information. Our analysis showed that 50% of the text in a patient record was directly duplicated from other text written about the same patient. This increased year-over-year and was more prevalent in records with more notes. This is an issue for physicians who spend significant time on clinical documentation.

Sort by Subjective

The SOAP method (Subjective, Objective, Assessment and Plan) efficiently organizes your clinical patient notes. This technique is a great way to ensure you’re writing your letters consistently and clearly. The SOAP technique is also helpful when understanding what’s going on with a patient.

Use the subjective section to record the patient’s symptoms or problems during your appointment. If multiple clinicians review the note, it’s essential to ensure all presenting issues are documented and any new problems are noted. In addition, enter the degree of adherence to previous treatment plans.

The objective section of the note documents data gathered from physical examination, laboratory results or imaging. This information typically focuses on the body, skin, head, eyes, ears, nose, throat, neck, respiratory, cardiovascular, abdomen/gastrointestinal, extremities and neurological. The note should also include a synthesis of both subjective and objective evidence to arrive at a diagnosis. This is commonly referred to as the “head-to-toe” assessment. It’s important to remember that this assessment is only sometimes complete, as it can depend on what’s causing the chief complaint.