Guidelines for Writing Notes

Sample Visit Note 1

Sample Visit Note 2

1. Patient's name, unit number, and visit date on each sheet
2. Write Your Name Clearly
   1. be willing to declare your identity and assume responsibility for your work.
   2. Clear writing of your name is an important courtesy to the patient and to other providers. Make it easy for other providers to locate you.
3. The organization should follow SOAP guidelines. SUBJECTIVE means only what the patient tells you (i.e.: symptoms, attributions, etc.) or what you know to have occurred in the past (i.e.: a medication change you made based on a telephone conversation with the patient). Results of consults can be placed here or in the objective section. Do not indicate impressions or results of your physical exam in the subjective section. OBJECTIVE includes results of physical examination and interval test data. ASSESSMENT includes you interpretation of information in the previous two session. PLAN is what you are going to do about your impression. I usually list my plan under each individual problem's assessment, as in the example above.
4. In general, do not list the past medical history. This should be clearly indicated on a master problem list. If the master list is not in the chart, make one after the visit.
5. Organize the “subjective” section by problems and be sure your problems reflect 1) the patient's agenda and 2) what you identify to be the important problems that need to be addressed during the visit (i.e.: the patient may not bring up health maintenance as a problem, but you should always list it in the subjective section).
   
   Use the same terms for problems so that a physician can quickly review the history of the problem by glancing at past visit notes.
6. List medications at least every other visit or whenever there have been important interval changes. USE GENERIC NAMES, INDICATE STRENGTH OF TABLET OR CAPSULE (At our clinic, patients may obtain refills by telephone. A nurse reviews most recent visit note for information on what medications are being taken, strength of tablets, signature, etc. If you are not clear in your notes, mistakes may occur).
7. Be sure the problems in the “assessment/plan” section correspond to those listed in the subjective section.
8. On every note indicate specific plan for follow-up (e.g.: RTC 2 weeks to see Dr. Kernan).
9. On every note, indicate name of supervising attending (e.g.: "seen with Dr. Kernan").