What is a medical note?
A medical note documents a patient’s healthcare visit and comprises part of his or her secure electronic health record (EHR) chart. Notes are written or dictated by physicians, nurses, physicians’ assistants, technicians, radiologists, and any other member of the patient’s healthcare team following an office visit, a telemedicine visit, a procedure, testing, therapy, or any other medical encounter.
Accurate and complete medical notes ensure systematic documentation of a patient’s medical history, history of present illness, diagnoses, past and current medications, allergies, treatment, and overall care. On this page, we’ll discuss the specific sections that comprise medical notes, different note types, and their importance in ensuring optimal, coordinated care.
What types of medical notes appear in patients’ EHR charts?
A patient’s medical chart may contain different types of EHR notes documenting office visits, telemedicine encounters, patient calls, and more, such as the following:
- Consultation notes
- Second-opinion notes
- Progress notes (i.e., follow-up notes)
- Referral notes from specialists
- Nurse notes
- Procedure notes
- SOAP notes
- Simple notes
- Phone notes
- Hospital notes
- Therapy notes (such as physical therapy, occupational therapy, psychology, or behavioral medicine notes)
What information should be included in a medical note?
As discussed above, patient charts include office notes for every patient visit or encounter, which contain specific information depending on the encounter type, including initial consultations, second opinions, follow-up visits, procedure visits, therapy visits, or encounters during which diagnostic testing takes place.
For a consultation, second-opinion, or follow-up visit, for example, the healthcare provider’s office visit note will include specific sections with all information relevant to the patient’s care, such as the following:
- Chief Complaint (CC) refers to a concise medical term or phrase describing the primary problem that led the patient to seek medical attention. Identifying the chief complaint enables the healthcare provider to focus on the priority for that day’s encounter while assessing the patient. It also helps the provider to direct the type of additional history to obtain as part of the evaluation and to determine appropriate physical examination regarding the reported problem.
- History of Present Illness (HPI) describes the progression of the patient’s present illness from initial symptoms to the date of the office visit.
- Review of Systems (ROS) is a listing of questions organized by organ system to identify malfunctioning and disease. ROS documentation indicates the patient’s answers to such questions vs. the physical examination note section (see below), where the provider documents what he or she physically observes through seeing, hearing, or measuring during examination.1
- Physical Examination may include the provider’s use of a stethoscope to evaluate heart rhythm and valvular function and tapping (percussion) and feeling with the hands (palpation) to determine size, position, consistency, texture, location, and tenderness of an organ or a bodily region. The provider may also measure pulse rate, height, and weight.
- Vital Signs may include the patient’s blood pressure, heart rate, respiratory rate, and more.
- Results may include lab results and imaging reports received electronically from lab or imaging interfaces, result documents that have been uploaded to the patient’s chart, or results added to a patient’s chart manually.
- Orders may include prescriptions, referral orders, lab testing, imaging studies, specific ordered procedures, and more.
- Assessment and Plan refer to the healthcare provider’s diagnostic conclusions and recommended plan for treatment, respectively.
Importantly, when documenting a note in the Practice Fusion EHR, you have the ability to easily and efficiently pull forward data from the patient’s chart into a new encounter note, including active medical history, PMH, PSH, family history, current medications, and allergies.
Many healthcare providers of different backgrounds and specialties may also document SOAP and Simple notes (non-SOAP notes) in their EHR patient charts. SOAP is an acronym, standing for the Subjective, Objective, Assessment, and Plan sections.2 In contrast, Simple notes have one free-text field that comprises the body of the note.
The Subjective section is the first heading of a SOAP note and describes the personal thoughts and feelings of the patient or a person close to him or her. The Objective section documents objective information that the healthcare provider obtained during the patient’s encounter. These may include vital signs, laboratory and imaging results, additional diagnostic data, physical exam findings, and review of documentation from other healthcare providers who are also part of the patient’s healthcare team.2
The SOAP note provides a framework for clinical reasoning and is a cognitive aid, guiding providers as they assess, diagnose, and treat their patients. In addition to documenting health status, SOAP notes serve as communication documents that assist in the coordination of care between clinical providers.2
How can Practice Fusion enhance your practice’s medical notes?
In addition to enabling providers to efficiently pull patient data from the EHR chart into new encounter notes, Practice Fusion provides practice-specific custom note types. This allows efficient capture of all pertinent information from your patient encounters in your notes, keeping your notes well-organized and providing an effective cognitive framework.
Medical notes can help tell your patient’s clinical story and your plan to methodically assess and appropriately treat the patient to resolve the medical problem and/or to relieve symptoms to enhance quality of life.4
Practice Fusion focuses on enabling providers to capture all of a patient’s key clinical data efficiently and effectively and to document medical notes in a manner that assists in optimal continuity of care among all members of a patient’s healthcare team. Practice Fusion enables healthcare providers to share medical notes and other chart data securely and quickly with other ambulatory practices, hospitals, laboratories, imaging centers, clinics, and, of course, patients themselves, increasing interoperability and streamlining and enhancing patient care.
Click here learn more about the Practice Fusion EHR.
- American Academy of Professional Coders (AAPC). Knowledge Base: How to distinguish ROS from Exam. September 4, 2012. Accessed on September 15, 2021. https://www.aapc.com/blog/21038-distinguish-ros-from-exam-to-prevent-double-dipping
- Podder V, Lew V., Ghassemzadeh S. SOAP notes. StatPearls (Internet). Last updated: September 3, 2020. Accessed on September 15, 2021. https://www.ncbi.nlm.nih.gov/books/NBK482263/
- Office for Civil Rights. Your rights under HIPAA. Last updated: November 2, 2020. Accessed on September 15, 2021. Your Rights Under HIPAA | HHS.gov.
- Robey T. Stating the Art and Science: The art of writing patient record notes. AMA Journal of Ethics: Illuminating the Art of Medicine. July 2011. Accessed on September 17, 2021.