It is efficient, saves time, and is great for billing, but it can make notes clunky and difficult to read. With the rise of electronic medical records (EMRs), there is a tendency to reduce as much of the note to checklists and bullets as possible. For instance, listing the DSM-5 criteria for major depression indicates which criteria are reported by the patient. An advantage of the narrative style is that it provides a clear picture, but the disadvantage is that it can be lengthy and time consuming.īullet-point/checklist style essentially lists the relevant information and symptoms without much detail or context. The best way to document information is by considering what is the best way to tell that story. It provides a meaningful account of “what happened?” and “what is going on?”. It is best suited for the history of present illness section. The narrative style involves telling a coherent story. Two broad categories of note-taking are the narrative style and the bullet-point/checklist style. An ideal note balances these different purposes. It is common to see very brief notes documenting minimal information needed for billing, and we also see very detailed documentation of medico-legal considerations but with little meaningful clinical information.

Securing oneself from a medico-legal perspective, for instance, by documenting an adequate suicide and violence risk assessmentĮveryone structures their notes differently, based on how much consideration is given to each purpose. Providing information to insurance companies and third parties that is adequate for billing and reimbursementĤ) Medico-legal considerations. This is particularly important when one writes consultation notes and discharge summariesģ) Billing and reimbursement. Communicating with colleagues (other physicians, social workers, etc.), who will utilize the notes as a source of information and guidance. Keeping track of clinical information for future reference and for the reference of future psychiatric/medical providersĢ) Communication. Listed below are some major reasons for medical documentation.ġ) Record-keeping. It is valuable for psychiatry trainees to reflect on multiple concurrent goals in order to develop a comprehensive note-writing style.

Medical documentation serves numerous functions. We recognize that these considerations might not apply to all clinical settings. In this article, we provide an overview of various aspects of taking notes and offer suggestions for effective documentation. While there are no shortcuts to cultivating this craft, many tips and considerations can be of enormous help for the trainees. Many residents struggle with documentation during their training, and they might not have a good idea of what elements to focus on. Note-taking is an art and a skill that is perfected over one’s career.

Place to write notes