How can you write clinical notes that are both concise and comprehensive?

Having a good EMR that allows for customizing your progress notes and evaluation is key. This allows a structure for your encounters that are consistent and you can add a combination of narrative lines along with check boxes based on what you prefer when doing notes. Most manage care frown upon the use of "templates" and copy features however if you use such templates and actually update the notes appropriately, it can save time in the long run. Treatment plans and having reminders to update them is another important feature when looking at EMRs.

It is essential to paint a complete and accurate picture of your patient's current health status. I find it most helpful when physicians use the assessment section of their note or EMR to document the Diagnosis, Status, and Plan for each acute and active chronic condition the patient has. This will allow billers to capture the necessary codes and auditors to validate your claims, especially for Medicare patients. This has become increasingly important for reimbursement and value-based care.

Remember who is going to be reading your clinical note. It may be another nurse, clinician, physician, discharge planner, case manager, or auditor. The audience of your note should impact the statements, clinical data, and context of what you write. All too often we see medical professionals transition from one role to another and not make the necessary adjustments to their documentation practices. Remember your audience.

Clinicians often battle how much to write in a note. You are writing the note for documentation for what transpired during your session, you are writing to justify the billing code you are billing and ensuring medical necessity in the services you are providing. Some detail may be needed to ensure the reader understands treatment focus, goals and objectives. Its a balance of what is necessary while still protecting the patient should records be requested in the future.

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Abbreviations and acronyms are often confusing and not best practice in documentation. I train nurses to stay away from them in their professional documentation.

Many consider the use of abbreviations in medical notes to not be representative of best practice. The chance of ambiguity increases significantly with well-intended shorthand.

Abbreviations can cause confusion in notes and may not be consistent with how others understand or define a term. For example IP - what does that mean? In patient? In person? Best practices is to ensure the meaning of your note is clear and causes no pause in understanding the content of the note.

I strongly suggest if your EMR or manner of documenting has spell check to use it. Otherwise, I wish more providers would take the time to review notes, ensure that spelling is correct for medications, names and terms. You want to ensure your note and message is clear and understandable, and typos can impact the meaning and understanding of the note. Your note is a reflection of you and your expertise, and having your notes show that is important.

Most practices struggle with ensuring notes are done in a timely and accurate fashion. Streamlining notes in a format that works for you is important. EMR's that allow flexibility in customizing notes, copying notes and allowing for treatment plan update notices can help ensure notes are done in a professional manner and meet managed care expectations for documentation.