Chart Keeping in Clinic

Clinic Record Keeping

The main purpose of a clinic encounter note is to RECORD AND COMMUNICATE the findings from the complaint, H&P, and the diagnostic reasoning, conclusion, and plans drawn from each patient encounter. These documents, along with others, will be included in the patient's hospital medical record. In order to efficiently and effectively communicate with other providers through your charts, it is always important to keep in mind that all notes should be WELL ORGANIZED, CONCISE, and CONVEY CLEARLY the observations and the thought process that led you to your conclusion and plan.  Always avoid carrying over unrefreshed "cut and pasted" sections from note to note. “Run-on” notes that goes way too long may impair the ability of others to understand what actually is going on with the patient, aim to limit your f/u notes to 1 page WebCIS small font.

The Standard AIM note template (aim for length of 1 page small font, 3 pages is WAY too long and likely reflect unprocessed data)

          Note Label/header (name, MRN, emergency contact info; AIM initial visit or follow up visit)

          Free text Problem List (must be reviewed and “weeded” at every visit, synthesize the problems as several may actually be related to one condition)

          Active

          Inactive (PMHX/PSurgHX)

          CC/HPI/ROS (interim hx)

          Med Allergy

          Updated Med List (Meds List reconciled and updated at every visit. Do bottle checks!!! Do not just copy and paste)

          FmHx

          SocHx

          Physical Exam

          Data (interpreted and summarized- do not pasted in huge chunks of radiology report)

          Assessment/Plan (one line summary of encounter at top. Then list problems and plan. Do not list by organ system)

          Health Maintenance

 

Take a thoughtful approach to the assessment/formulation section and use it to provide a big picture view of what is going on with the patient. Assessment and plans should be summarized BY PROBLEM (not organ system). Problems may be diagnosed diseases/syndromes, or symptoms, symptom complexes, or abnormalities from the exam, labs, or imaging.  If you prescribe a medication or order a test, be sure to write out your reasoning and plan for that particular approach.  Updating health maintenance and preventive measures should always be part of you’re A/P. Click on our website’s note samples (look under charting) to see samples of different visit formats. 

In addition to the official medical records, the intern will be provided his/her own binder for organizing his/her clinic paperwork. This binder is kept in the closet in your home Firm (near the back door lockers), and allows you to maintain a personal on-site file for a shadow clinic records or test results, outside paperwork, or copies of your favorite patient hand outs.

Click on the notes below to see samples of different visit formats (of note the font on these documents are different from what exist in Eclipsys)

·         Sample Note Template

·         Sample Note - New Patient and summarized

·         Sample Note - Follow Up Visit

·         Sample Note - Complex New Patient

·         Sample Note - Complex Follow Up Patient