Doctor clinical notes
What are Doctor Clinical Notes?
Doctor clinical notes or doctor medical notes are the records of the patient that are created by the doctor during an appointment with them. They are sometimes referred to as clerking within the medical community.
Doctor clinical notes are used to document the patient’s health history and diagnose any medical issue. A doctor typically creates a note at the conclusion of an appointment in order to record information about the patient’s physical and mental health.
Doctor clinical notes can be used for several purposes, including but not limited to:
- Establishing a medical diagnosis
- Recording all that was discussed during the appointment in order to review it on future appointments or with other physicians in case of emergency
- Documenting medication intake, lab results, and other information related to patient care.
Clinical documentation is absolutely critical to proper patient care and treatment. Without it, doctors will have to spend hours to re-collect, diagnose, evaluate each and every patient. Doctor clinical notes enable doctors a quick reference for their patient’s medical information.
Doctor clinical notes generally follow frameworks such as SOAP, SBAR or CAPS (more on that below). These frameworks make it easier and quicker for doctors to organise information and refer back to when required.
SOAP Notes
SOAP is an acronym for Subjective, Objective, Assessment, Plan. SOAP notes are typically found in electronic medical records (EMR) and is a common framework adopted by various healthcare providers.
SOAP notes is a method of documentation employed by healthcare providers to write out notes in a doctor clinical note, it is commonly used along with other common formats, such as the admission note.
SBAR Note
SBAR is an acronym for Situation, Background, Assessment, Recommendation. The SBAR note provides a framework for communication between healthcare providers and their team about a patient’s condition.
CAPS
CAPS is an acronym for Concern, Assessment, Plan, Supporting Information. It is a Clinical Assessment Protocol that helps doctors focus on key issues identified during the assessment process, so that decisions as to whether and how to intervene can be explored with their patients.
How does Doctor Clinical Note improves patient outcome and satisfaction
As the saying goes – information is king. Clinical documentation forms the essential foundation of a patient’s medical record, it improves patient outcome and satisfaction via a few ways.
Capturing Critical Information Accurately
Clinical documentation forms the essential foundation of a patient’s medical record. It captures critical information such as patient care information from admission to discharge, including diagnoses, treatment and resources used during their care.
When clinical documentation is accurate, detailed, and complete, it prevents ambiguity, and improves communication between healthcare providers. On the flip side, clinical documentation that is incomplete or inaccurate can seriously affect the quality of patients’ care. This can lead to negative consequences such as medication errors, longer lengths of stay, inappropriate (or no) post-discharge patient follow-up, or higher readmission rates and increased care costs. All these leads to negative patient experience and could affect the reputation of the healthcare provider.
A study conducted by 3M Canada Health Information Systems found that more than 50% of medical records in most hospitals could be improved with more complete and accurate clinical documentation.
Enables Doctors To Diagnose Patients Quickly & Save Time
Doctor clinical notes help doctors by detailing patient history and treatment plans. This in turn enables doctors to diagnose their patients accurately, quickly, and provide appropriate treatment and care for their patients. It also helps doctors avoid conducting duplicate tests or assessments, saving them time.
Motivate Patients
A lesser known benefit of doctor clinical notes is their ability to motivate patients to adhere to treatment plans prescribed by their doctors.
A study published in the Journal of General Internal Medicine found that 50% of clinicians first trying open clinical notes ended up saying their patients took better care of themselves when given access. And about 75% of healthcare providers said they saw better patient empowerment.
Another study published in the Annals of Internal Medicine showed that open clinical note access improved medication adherence for 14% of patients. Patients with access to doctors’ clinical notes helped 64% of patient respondents better understand why their doctors prescribed certain medications, and another 62% of patients felt more in control of their medications. 57% of respondents said they were able to find answers to questions they had about their medications, saving them a call to their doctors.
Accurate and concise documentation is critical for healthcare providers to provide patients with quality care, and helps healthcare providers evaluate and plan the patient’s treatment and maintain the continuum of care.
The end result of the abovementioned benefits would be that treatments will have better outcomes and patients will be more satisfied with their doctors. This is beneficial not only for the patients, but for the reputation of the doctor and his/her clinic too.
With the rise of technology, many healthcare providers are adopting electronic medical record systems to simplify and improve the process of recording patients information in their clinical notes.
Galen Health’s Clinic Management System contains a doctor clinical notes feature alongside other essential features to simplify healthcare providers work and make their life easier.
What information is included in a Doctor Clinical Note?
Doctors generally follow frameworks such as SOAP, SBAR or CAPS when drafting their clinical notes. These frameworks make it easier and quicker for doctors to organise and reference information.
With the rise of electronic medical reports (EMR), healthcare practitioners are able to capture and record more patient information than ever before. This benefits doctors as they’ll have more information to assist their diagnosis and treatment recommendation. It also benefits patients as they’ll receive better and more personalised care.
Some key information that a good doctor clinical note will contain are in a non-exhaustive list below:
1: Administrative and billing data
Doctor clinical notes often contain basic administrative and billing data that are required to enable a clinic or healthcare provider to bill their patients and provide custom care for them.
2: Patient demographics
Patient demographics provides doctors with basic profile information about their patients. These are basic information that should be included in every doctor’s clinical note.
3: Doctor clinical notes or progress notes
Doctor clinical notes are used to document the patient’s health history and diagnose any medical issue. Doctors could also take notes of the patient’s recovery process. This enables doctors an easy way to track their patients progress over time. They can also be shared with patients to motivate them to adhere to their treatment or recovery plan.
4: Vital signs
Vital signs are critical medical signs that indicate the status of the body’s life-sustaining functions. Vital signs can help doctors assess the general health of a patient, and give clues to possible diseases, or show progress toward recovery. They are an essential part of a clinical note.
A good doctor’s clinical note will have a section that allows healthcare providers to record their patients vital signs. And possibly measure them over time.
5: Medical history
Medical history is a record of information about a patient’s past and current health. It may sometimes also include the medical history of the patient’s family members (parents, grandparents, children, brothers, and sisters).
A family medical history may show a pattern of certain diseases in a family. Which can assist doctors in diagnosing patients and recommending the appropriate treatment.
It is important for a doctor’s clinical note to contain a section to record the medical history of the patient.
6: Diagnosis
Medical diagnosis is the classification of an individual’s condition into specific categories that allow the doctor to make medical decisions and provide appropriate treatment to the patients.
A diagnosis may include:
- A detection of anomalies or symptoms by the doctor of their patient
- Complaints made by patients that may be relevant to their condition
- A medical fact of the patient uncovered through tests
7: Medications
Records of medications that the patient has been issued, or is currently taking is a key piece of information to doctors. This enables doctors to recommend the appropriate treatment to patients.
Every doctor’s clinical note should contain a section to record the medication history of the patient.
8: Immunisation dates
Immunisation dates record the history of a patient’s immunisation. This information can be used by doctors to assist in the diagnosis and recommendation of treatment for their patients.
9: Allergies
A critical piece of information, every clinical note should have a record of patients’ allergies. This will help doctors diagnose their patients more accurately as well as provide treatment or medication suitable for their patients.
10: Radiology images
If a patient has undergone radiology imaging, doctors may want to refer to their radiology images in a quick and simple manner. A good doctor’s clinical note will have the capacity to store patients radiology images for easy reference by their doctors.
11: Lab and test results
Similar to the point above. A good doctor’s clinical note will have the capacity to store a patient’s lab and test results. This helps doctors access the information quickly and easily, saving time for doctors and enabling them to provide swift care for their patients.
Why You Need a Medical Records System in Your Practice
Medical records system is a system that is used in the healthcare sector to maintain the medical records of patients. Medical records systems may be used by hospitals, clinics, pharmacies, laboratories and other healthcare providers.
Medical records systems are first and foremost designed to capture, process, store and retrieve patient documentation so that it can be accessed by providers and staff when needed. This information is usually stored in a centralised repository called the electronic health record (EHR), or electronic patient record.
Historically, doctor clinical notes are often handwritten and manually stored in physical folders and/or excel sheets. Organising and maintaining your doctor clinical notes manually and without a proper system can soon get overwhelming for a clinic very quickly.
The biggest benefit of medical record systems is that they help doctors and healthcare practitioners to organise and maintain their clinical notes electronically. This is a much more effective way of managing and organising patient information and saves the clinic tons of time.
A good medical record system will help clinics improve their operating efficiency. This in turn reduces their operating cost and enables them to provide their patients with better care and treatment, improving patient satisfaction.
Galen Health’s Clinic Management System contains a medical records system feature alongside other essential features to simplify healthcare providers work and make their life easier.
Why should a doctor use Galen Health’s Clinic Management System?
As a healthcare practitioner, your patients are your priority, all other non-core functions simply serve to distract you from providing quality service to your patients. A good health clinic management system helps you by streamlining and automating these functions.
Galen Health’s Clinic Management System helps you by simplifying day-to-day operations with an easy-to-use clinic management software, so that you can focus on your patients.
Their system has multiple essential features and key integrations such as patient scheduling and registration feature Electronic Medical Reports (EMR), doctor clinical notes, lab report integration, claims management and more. These features are built specifically to make healthcare practitioners’ lives easier.
Galen Health’s Clinic Management System also has secure end-to-end encryption, this ensures the privacy and security of your patients data.
As a SmartCMS Programme Gold Tier 1 participant, Galen Health’s Clinic Management System is fully-integrated with the public healthcare system and programmes such as CHAS and PHPC. It supports the seamless integration flow between clinics and public healthcare systems. They are also trusted by some of the most renowned clinics across Singapore.
Galen Health’s Clinic Management System is trusted by some of the most renowned healthcare names in Singapore. Including Healthway Medical, SBCC (formerly known as Singapore Baby and Child Clinic), The Clinic Group, Tooth Stories and more.
Galen Health’s Clinic Management System is the perfect Clinic Management System, built for Solo Practitioners, Medical Groups and Hospitals. They offer free set up, free onboarding and training, free demo and a 24 hour support.
In the end, Galen Health’s Clinic Management System benefits all healthcare practitioners by helping them reduce yours and your staff workload, improve operating efficiency, and increase patients satisfaction. Your staff will be thanking you for implementing this system in your healthcare practice.
