The official documentation created during a patient encounter, often referred to as “doctor’s notes,” is a comprehensive record of a person’s health history, current condition, and treatment plan. These records serve several interconnected functions. They are formally maintained to ensure seamless communication between various healthcare providers, establish a consistent record for continuity of care, and function as the official legal document of the services rendered.
The Purpose and Structure of Clinical Notes
Clinical notes are formally part of the patient’s Health Record and are primarily written for an audience of other medical professionals, which dictates their structure and content. A widely adopted format for progress notes is the acronym SOAP, which stands for Subjective, Objective, Assessment, and Plan. This structure provides a standardized, logical flow for documenting a patient encounter, ensuring that no essential component of the clinical reasoning process is missed.
The notes ensure that clinical decisions are transparent and supported by the documented evidence. This continuity is important when a patient is seen by multiple specialists or transfers care between different facilities.
The SOAP framework acts as a cognitive aid for clinicians, guiding them through the steps of gathering information, interpreting findings, arriving at a conclusion, and outlining the next steps for care. This formal documentation also serves as a legal record of the care provided, which requires all entries to be accurate, timely, and clearly linked to the patient’s presentation.
The Specifics of Diagnosis and Assessment
A doctor’s note explicitly answers the question of “what is wrong” within the section labeled “Assessment.” This portion of the note is where the healthcare provider synthesizes the information gathered from the subjective and objective sections to arrive at a clinical conclusion. The diagnosis is the professional determination of the patient’s condition, differentiating it from the initial symptoms or complaints.
The Assessment typically lists the problem or problems in order of importance, sometimes including differential diagnoses—a list of possible conditions considered before the final determination. Crucially, the diagnosis is documented using an internationally recognized classification system, such as the International Classification of Diseases, Tenth Revision, Clinical Modification, known as ICD-10-CM codes. These codes are alphanumeric sequences of up to seven characters that classify every disease, symptom, injury, and cause of death.
These standardized codes ensure that a diagnosis like “Type 2 diabetes mellitus” is uniformly represented, for instance by the code E11.9, regardless of the clinician or facility. The use of ICD-10-CM codes is mandated for billing purposes and for communicating diagnostic information across the entire healthcare system. While the diagnosis is a concise statement or code, it represents the culmination of the provider’s professional analysis of the patient’s subjective report and objective findings.
What Patients Are Legally Allowed to View
Patients possess a legal right to access their medical records, a right established and reinforced by federal law. The Health Insurance Portability and Accountability Act, or HIPAA, gives patients the right to obtain a copy of their protected health information, including their clinical notes. More recently, the 21st Century Cures Act significantly expanded and accelerated this access.
The Cures Act mandates that healthcare providers must not block a patient’s access to their electronic health information, a principle known as “information blocking.” This rule requires the timely, often immediate, release of eight specific types of clinical notes, including progress notes and discharge summaries, typically through patient portals. This immediate digital access empowers patients to become more active participants in their care, review the doctor’s reasoning, and catch potential errors in their record.
Why Understanding the Notes Can Be Difficult
Despite having the legal right to view their notes, many patients experience frustration when attempting to interpret the content. Clinical notes are written for rapid communication between clinicians, which leads to heavy reliance on medical abbreviations and specialized jargon. Common abbreviations like “MI” for myocardial infarction (heart attack) or “HTN” for hypertension (high blood pressure) can be confusing, especially since many abbreviations have multiple possible meanings.
This clinical shorthand is coupled with technical terminology that may have a different meaning in a medical context than in common usage. For example, a note might describe a physical exam finding as “grossly intact,” where “grossly” means “in general” or “overall,” not unpleasant. Patients can look up ICD-10 codes or common abbreviations online, but the most effective strategy for clarification is always to ask the healthcare provider directly during or after the appointment.