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

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.

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

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

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.

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

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

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