A doctor’s note, formally known as clinical documentation, is a comprehensive record of a patient’s interaction with the healthcare system. This documentation serves as a professional communication tool, ensuring the care team understands the patient’s condition and treatment history. The note also functions as a permanent, legal record of the encounter, fundamental for maintaining continuity of care across different providers and settings.
Common Structural Formats
Clinical notes adhere to standardized structures designed for efficiency and clarity among medical professionals. The most widely used format for routine care is the SOAP note, standing for Subjective, Objective, Assessment, and Plan. This four-part structure organizes information logically, making it easy for a clinician to quickly review a patient’s progress over multiple appointments.
For comprehensive initial encounters, such as hospital admission or a first consultation, the History and Physical (H&P) format is employed. The H&P is a longer, detailed document that systematically captures the patient’s complete medical background and current status. Specialized documentation, like operative notes or discharge summaries, follows distinct structures to ensure all legally required information pertinent to that specific event is recorded.
The Essential Content of a Clinical Note
Regardless of the format, the content breaks down into specific categories the provider must document. The Subjective section captures the patient’s narrative, including the chief complaint (the main reason for the visit), often recorded in the patient’s own words. This section details the history of the present illness, covering the onset, location, duration, and quality of symptoms, as well as any relevant past medical, social, or family history.
The Objective section contains measurable, verifiable data collected during the encounter. This includes the patient’s vital signs—such as blood pressure, heart rate, and respiratory rate—along with findings from the physical examination. Laboratory results, imaging reports, or other diagnostic test data are also logged here to provide an unbiased snapshot of the patient’s physiological state.
Following the collection of subjective and objective information, the Assessment section is where the clinician synthesizes the data to form a professional impression. This section typically lists the diagnosis or a differential diagnosis, which is the working theory of possible conditions explaining the patient’s symptoms. The Plan then outlines the proposed next steps for managing the patient’s health, detailing prescribed medications, procedures, referrals, and the schedule for follow-up appointments.
Why Medical Notes Are Difficult to Read
The primary audience for clinical notes has traditionally been other healthcare professionals, which is why patients often find the documentation challenging to understand. Notes are dense with medical jargon, using technical terminology like “malaise” instead of “feeling unwell” or “dyspnea” for “shortness of breath.” Studies show that electronic health record (EHR) notes are often written at an 8th to 12th-grade reading level, significantly higher than the average reading level of the general adult population.
A barrier to readability is the extensive use of abbreviations and medical shorthand. Clinicians use acronyms like “SOB” for shortness of breath or “BID” for two times a day to save time. These are often confusing to lay readers, and some abbreviations can even have multiple meanings depending on the specialty.
The shift to EHRs has contributed to notes that contain generic or templated language. Phrases like “WNL” (within normal limits) or copied-and-pasted text from previous encounters can obscure subtle changes in a patient’s condition.
Patient Access and Rights to Their Medical Notes
Patients in the United States have a legally protected right to easily access their clinical documentation. The Health Insurance Portability and Accountability Act (HIPAA) established the right to request copies of records, but the process was often slow and costly. The 21st Century Cures Act, specifically its information blocking provisions, mandated that healthcare providers must give patients rapid, free, and electronic access to their clinical notes and test results without delay.
This mandate is largely fulfilled through secure online patient portals, such as MyChart, which allow individuals to view their documentation almost immediately after it has been finalized by the provider. The intent is to promote transparency and empower patients to be more involved in their own care, a movement often referred to as OpenNotes. While the notes may still contain complex medical terminology, patients are encouraged to use this access to prepare questions for their next appointment and discuss any confusing content directly with their provider.