How to write shorter clinical notes

January 24, 2023

How to write shorter clinical notes

Here are tips you can borrow to write concise clinical notes. While keeping them clear and thorough. And spending less time on EMR documentation.

Keep in mind that these suggestions are not for everyone. Use just those that fits your documentation style.

Don't write paragraphs

You're not writing a novel. Think bullet lists. They are easier to read.

DON'T DO
The patient is complaining of headache that has been intermittent over the last week. She scales the pain at 6 out of 10. She denies having nausea, vomiting or light sensitivity. She denies any past medical history of migraine. • Complains of headache
• Started a week ago and is intermittent
• Scaled at 6/10
• No nausea, no vomiting, no light sensitivity
• No prior migraine

Cut on pronouns

This is useful when using Dilato shortcuts (or dot phrases): you don't need to replace all pronouns for the correct gender.

DON'T DO
Patient is a 44 y/o female complaining of abdominal pain.
She reports it's on the epigastric area.
Her pain is described as sharp, and scaled at 8 / 10.
She states she had her gallbladder removed last year.
Patient is a 44 y/o female complaining of abdominal pain.
Reports it's on the epigastric area.
Pain described as sharp, and scaled at 8 / 10.
Had gallbladder removed last year.

Use abbreviations

Medical abbreviations are time savers. However, use only approved abbreviations.

DON'T DO
Assessment / Plan:
Acute otitis media on the right ear
- Nasal cleaning with normal saline, every 4 hours.
- Will start antibiotic if fever or not better in 2 days
A/P:
AOM on R
- Nasal cleaning with NS, q 4 hrs
- Will start ABX if fever or not better in 2 days


Use shorter phrases

Don't spend time typing a long phrase when a shorter alternative is just as clear.

DON'T DO
Denies nausea as well as diarrhea

The UID cords have been vizualized

Patient was not very good at reporting his symptoms
No nausea or diarrhea

UID cords were seen

Patient is a poor historian

Use symbols

Symbols add readability. You can insert them quickly with shortcuts using a text replacement tool.

DON'T DO
Furosemide increased to 40 mg BID
Expected to lose approximately 10 lbs
Will decrease dosage if diuresis is more than 500 cc in 8 hr
Furosemide 40 mg BID
Expected to lose 10 lbs
Will decrease dosage if diuresis 500 cc in 8 hr

THE NEXT TIPS WON'T SHORTEN YOUR NOTES BUT THEY WILL HELP YOU SPEND LESS TIME ON CHARTING.

Don't capitalize every first letter

Skip the shift key if you're not good at using it. Lowercase notes are still clear and thorough.

DON'T DO
Steroid injection of the right lateral epicondyle: Risks and benefits discussed and consent obtained Prepped in sterile manner Depo-Medrol 40mg/cc 0.5 cc + Lidocaine 1% without epi 1 cc injected into affected area Procedure well tolerated without complications Post-procedure care explained and return precautions given steroid injection of the right lateral epicondyle: risks and benefits discussed and consent obtained prepped in sterile manner depomedrol 40mg/cc 0.5 cc + lidocaine 1% without epi 1 cc injected into affected area procedure well tolerated without complications post-procedure care explained and return precautions given

Restrain from correcting all typos

Learn to accept some typos and incorrect spelling. Correct only what needs to be for clarity. (Not for everyone.)

DON'T DO
Wants to start contraception
Prior contraception: intrauterine device
Last menstrual period: Aug 24th
Cycle: 28 days
Moderate dysmenorrhea
Last Pap smear: 1 year ago
Wants to start contraception
Prior contraception: intrautrine device
Lastmenstrual period:Aug 24th
Cycle: 28 day
mOderate dysmenorrhea
Last Pap smaer: 1 year ago

Add periods only when necessary

Use punctuation only if it brings more readability.

DON'T DO
Consent obtained.
Area prepped and draped.
Local anesthesia with 3 cc lidocaine 1%, with epi.
Incision made, small amount of purulent material expressed.
Abscess explored and pockets opened.
Bleeding minimal, no complications.
Consent obtained
Area prepped and draped
Local anesthesia with 3 cc lidocaine 1% with epi
Incision made
Small amount of purulent material expressed
Abscess explored and pockets opened
Bleeding minimal, no complications