Note Writing

Clinical notes serve a variety of purposes in modern medical care. Documentation records the care provided, communicates the plan of care to the entire care team, and supports the level of service billed by the attending physician. Clinical documentation may also be cited as evidence in a court of law. Therefore, it is important to approach note writing with careful consideration, particularly when you’re learning this skill for the first time. This chapter will review key aspects of writing a complete and well-reasoned note.