Writing a Clinic Note

Abstract

Note-writing is an essential part of the experience for medical students working in the clinic. The progress note is where the physician documents the encounter and commits to a diagnosis and treatment plan. The progress note serves both to communicate medical information about the encounter to other clinicians and to document the visit for medicolegal purposes. In the SOAP-style clinic note, the Subjective should be a concise summary of events since the last visit, focusing on active chronic conditions, new symptoms, and a targeted review of systems. The Objective comprises today’s vital signs, vital sign trends, and pertinent physical exam, lab, and imaging findings. The Assessment and Plan must include a brief assessment for each active problem, a discussion of significant new findings—including a differential diagnosis as appropriate—and discussion of treatment and testing options, including the patient’s preferences, risks, benefits, and costs. To write succinct, effective clinic notes, things to avoid include purple prose, missing problem lists, cluttered notes, shows of erudition, cutting and pasting, “problems not addressed,” and criticism of colleagues. Several examples of concise, readable SOAP-style clinic and telemedicine notes are given at the end of the chapter.