Clinical Notes: Best Practices and Examples

Clinical notes are an essential component of patient care, providing a detailed account of patient interactions, diagnoses, treatment plans, and follow-up care.

For Direct Care physicians, crafting high-quality clinical notes is crucial to ensuring comprehensive patient care, facilitating communication, and maintaining accurate records.

This guide explores the best practices for writing clinical notes, various methodologies, and provides examples to illustrate effective note-taking.

What Are the Best Clinical Notes?

The best clinical notes are clear, concise, and comprehensive. They should provide enough detail to support patient care decisions, document the patient’s health status, and comply with legal and regulatory requirements. Good clinical notes should:

Clearly outline the patient’s medical history, current condition, and treatment plan.
Be organized in a logical structure, making it easy to understand. Use a consistent format and structure for all notes to ensure they are easy to follow.
Include objective data, such as vital signs and lab results, alongside subjective information, like patient complaints and observations. Document facts and observations without inserting personal opinions.
Be free of jargon and abbreviations that could lead to misunderstandings.
Ensure accuracy and completeness, avoiding any potential legal issues or misinterpretations. Write notes as soon as possible after the patient encounter to ensure accuracy.

Several methodologies can be used for writing clinical notes, each with its unique structure and focus. Here are three widely-used methods.

Clinical Notes Type #1: SOAP Note

SOAP is an acronym for a method of documentation employed by clinicians to write out notes in a patient's chart. The SOAP note method is structured as follows:

Subjective: Document the patient’s verbalized symptoms and concerns.
Objective: Record measurable data such as vital signs, physical exam findings, and lab results.
Assessment: Provide a diagnosis based on the subjective and objective data.
Plan: Outline the treatment plan, including medications, procedures, and follow-up care.

Example of a SOAP note:

S: Patient reports a sharp pain in the right lower abdomen for the past 24 hours.
O: Temperature 98.6°F, BP 120/80, tenderness in the right lower quadrant.
A: Suspected appendicitis.
P: Refer to surgery for evaluation, initiate IV fluids, and pain management.

Clinical Notes Type #2: DAP Note

DAP is a simplified method of clinical documentation used to record patient interactions and therapy sessions:

Data: Collect all relevant patient data, including subjective and objective information.
Assessment: Analyze the data to form a clinical judgment or diagnosis.
Plan: Develop a plan of action based on the assessment.

Example of a DAP Note

D: Patient complains of chronic cough, worsening at night, with a history of asthma.
A: Likely asthma exacerbation.
P: Prescribe inhaled corticosteroids, advise on avoiding triggers, and schedule a follow-up in two weeks.

Clinical Notes Type #3: BIRP Note

BIRP is a documentation method used primarily in behavioral health to record therapy sessions and progress:

Behavior: Document observed behaviors and patient’s reported experiences.
Intervention: Note the interventions provided during the visit.
Response: Record the patient’s response to the interventions.
Plan: Outline the future care plan, including any changes in treatment.

Example of a BIRP Note

B: Patient appears anxious, reports difficulty sleeping, and increased stress at work.
I: Provided counseling on stress management techniques.
R: Patient seemed more relaxed after the session and expressed willingness to try the suggested techniques.
P: Follow-up in one month, consider referral to a mental health specialist if symptoms persist.

By utilizing these structured methodologies and adhering to best practices, you can create clinical notes that enhance patient care, streamline communication among providers, and ensure accurate and comprehensive documentation.

Clinical Notes in SigmaMD

In our commitment to alleviate clinical burden and elevate patient care, we are thrilled to unveil our new Clinical Notes feature. This feature is designed to enhance your patient documentation experience, making it more structured, efficient, and enriching.

Clinical Notes with Macros and Variables

As you embark on a patient encounter, the feature presents a dedicated text field, paving the way for detailed and organized documentation. Formatting tools are at your disposal to emphasize text, structure your notes, and ensure clarity, making your documentation journey smooth and enjoyable.

The hallmark of our Clinical Notes lies in its dynamic functionalities. The feature houses Macros, a powerful tool that speeds up the documentation process while adding depth. Begin with the / shortcut to embed pre-configured text snippets curated by you or your peers. This is especially invaluable for note templates or frequently used phrases.

Variables are another noteworthy aspect. Use the $ shortcut to insert predefined data from the patient chart such as $patientAge or $patientFullName, making the documentation more personalized and accurate.

Moreover, the feature introduces Note Blockers to ensure no crucial information is missed before signing off the notes. Type {{!}} on your macros wherever you want some information to be added and the note blocker prevents you from signing the note before you review and remove it.

Scenario Snapshot: Example of a Physician Managing Clinical Notes

Let's explore this with an example: imagine you're in an encounter with a patient who has high blood pressure. By simply typing /, you can trigger a macro for a standard hypertension encounter note. This macro populates a template with SOAP sections, including a Note Blocker at the Objective section to remind you to input the physical examination results. This feature not only speeds up the documentation process but also ensures a thorough note is crafted without overlooking crucial details.

This note template can also encompass common text elements shared with other templates, such as your signature or a header. These elements can utilize variables to auto-fill the patient's name and date of birth.

When it's time to finalize your note, the template's blocker prevents signing until you've recorded the vital measurements. Once you remove the blocker and input the measurements into the patient's chart, they will be automatically integrated into the note. With a final signature, your documentation is complete and ready!

At SigmaMD, we're all about making things better. Our new auto-save feature and detailed logging of changes after signing show our effort to keep your work safe and clear. This is just the start. We're working hard to improve the Clinical Notes interface to make documenting easier and help improve patient care. With each note, we're one step closer to exceptional patient care, and we're excited about the updates we have planned.

Stay tuned for more features that will help make your practice more efficient and focused on patients.