By Kiwi Health
Published: Aug 24, 2023
With the enactment of the ONC Cures Rule in 2021, which revolutionized the healthcare landscape, the significance of accurate and comprehensive clinical notes has never been greater.
After all, being transparent and direct with patients goes a long way toward building trust and reliability. And with the wide availability of information on the web, people can get confused when they search for symptoms and read diagnoses that can be inaccurate and generalized.
Patient: “I have a headache.”
Google: “You might be experiencing symptoms of a tumor in your brain.”
That’s why knowing how to jot down clinical and therapy notes is essential accurately.
Whether you’re a nurse or belong to a group of mental health professionals, there’s no denying that clinical note-taking is crucial for both parties: your patient and yourself.
So join Kiwi Health on an enlightening journey as we delve into the essentials of crafting impeccable clinical note-taking, ensuring seamless communication, improved patient outcomes, and compliance with the latest healthcare regulations.
For any healthcare professional, rushed therapy notes can be detrimental to their reputation in the healthcare industry.
It’s quite understandable that sometimes life gets in the way, and you might get busy as a bee, jumping from one appointment to the next. But note-taking shouldn’t be taken lightly for the following reasons:
Let’s say you’re a therapist, and after the first therapy session, you’d want to be more organized to keep track of your client’s therapy progress notes.
What should you include when writing progress notes to make things easier for you when you check back again in future sessions?
When you sit down to write therapy notes or other kinds of clinical information, it’s essential to include the following key information to ensure comprehensive and accurate documentation:
The SOAP note is a widely used and effective method for clinical documentation, providing a structured framework for organizing patient information.
Understanding and adopting the SOAP note format can significantly improve the quality and consistency of your clinical documentation.
Here’s a breakdown of the SOAP note:
S – Subjective: In this section, document the patient’s subjective information, including their chief complaint, symptoms, and any relevant history of present illness (HPI) provided by the patient.
O – Objective: This part involves recording the objective and measurable data gathered during the patient’s examination, such as vital signs, physical exam findings, diagnostic test results, and any other relevant observations.
A – Assessment: The assessment section involves your professional evaluation and analysis of the patient’s condition. This is where you formulate a diagnosis and identify any potential problems or issues.
P – Plan: The plan outlines the proposed course of action for the patient’s care. It includes treatment plans, prescribed medications, follow-up instructions, referrals, and any additional diagnostic tests or procedures.
S – Subjective: Patient complains of persistent abdominal pain, rates pain at 7/10, and reports nausea and vomiting.
O – Objective: Physical exam reveals tenderness in the right lower quadrant, elevated temperature (100.4°F), and increased white blood cell count (WBC).
A – Assessment: Suspected appendicitis based on clinical presentation and exam findings.
P – Plan: Consultation with a surgeon for possible appendectomy, administer IV fluids and pain medications, monitor closely.
Chief Complaint: The patient presents with a sore throat and difficulty swallowing for the past two days.
History of Present Illness: Reports experiencing a mild fever and fatigue; denies cough or nasal congestion.
Past Medical History: No significant medical history or recent travel.
Assessment: Suspected viral pharyngitis based on symptoms and absence of respiratory symptoms.
Plan: Recommend rest, increase fluid intake, and over-the-counter pain relievers for symptom relief. Advise follow-up if symptoms worsen.
07/15/2023 – Patient arrived for a follow-up appointment after cardiac surgery. Reports feeling more energetic and less shortness of breath.
Physical examination shows a stable surgical incision with no signs of infection. Heart sounds are regular, no murmurs or abnormal rhythms detected. Patient tolerates medications well.
Plan: Continue current medication regimen, schedule cardiac rehabilitation sessions, and follow up in two weeks.
In all these examples, the clinical notes are well-structured, containing relevant subjective and objective information, a clear assessment, and a comprehensive plan of care.
The notes provide a snapshot of the patient’s condition, guiding further treatment decisions and facilitating effective communication among healthcare providers.
The type of clinical notes you choose to use depends on various factors, including your practice setting, patient needs, and personal preferences.
Here are some common types of clinical notes and their characteristics to help you make an informed decision:
Ultimately, the best type of clinical notes to choose depends on the specific needs of your practice and the level of detail required for each patient encounter.
Many healthcare professionals use a combination of note formats based on the clinical situation, tailoring their documentation to ensure accuracy, efficiency, and effective communication.
Clinical note-taking carries significant legal implications, as accurate and comprehensive documentation is crucial for patient care, legal protection, and regulatory compliance.
Here are some essential legal considerations to keep in mind when taking clinical notes:
Clinical notes serve as a record of patient interactions and the care provided.
In case of a medical malpractice claim, these notes may be used as evidence to defend or challenge the care provided. Therefore, it’s essential to ensure that the notes are accurate, thorough, and reflect the standard of care.
Clinical notes contain sensitive patient information, making privacy and security-critical. Ensure that you follow the Health Insurance Portability and Accountability Act (HIPAA) guidelines and maintain patient confidentiality when documenting and storing clinical notes.
If a procedure or treatment requires informed consent, ensure that the documentation includes the patient’s understanding and agreement to proceed.
Make sure that the clinical notes are legible and recorded in a timely manner. Delayed or illegible documentation may raise concerns about the accuracy and reliability of the information.
Use objective language in your clinical notes, avoiding subjective opinions or judgments. Stick to the facts and avoid making assumptions or conjectures.
If you make an error in your clinical notes, do not erase or delete it. Instead, make a single line through the mistake, write “error,” and then provide the correct information along with your initials and the date.
Be consistent in your note-taking format and ensure that all relevant information is recorded, including patient complaints, physical exam findings, assessments, plans, and any patient education provided.
Know the record retention policies and legal requirements in your jurisdiction. Keep clinical notes and patient records for the required duration to comply with legal and regulatory obligations.
Adhere to ethical principles in your clinical note-taking, such as respecting patient autonomy, avoiding conflicts of interest, and maintaining professional boundaries.
Accurate clinical notes support effective communication and collaboration among healthcare providers, promoting continuity of care and improved patient outcomes.
Taking control of your clinical notes is essential for delivering exceptional patient care, mitigating legal risks, and ensuring seamless communication among healthcare providers.
Accurate, comprehensive, and timely documentation is the cornerstone of effective medical practice, supporting patient safety and positive outcomes.
By practicing and perfecting your clinical note-taking skills, you become an essential part of this healthcare communication process.
Your notes act as a testament to your patients’ journey through the healthcare system, a written record that can inspire and motivate them through challenges and contribute to their overall sense of progress and achievement.
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