Documentation

Notes are thinking made portable

A progress note is SOAP with the assessment doing the heavy lifting: Subjective (what changed for the patient), Objective (vitals trends, focused exam, new results), Assessment (the problem list, each with a one-line status and reasoning), Plan (by problem, with owners and stop-rules). The problem-ordered A&P is internal medicine's native data structure.

The four notes

Admission notes argue a case (full history, representation, ranked differential, plan). Progress notes update one (delta-focused). Consult notes answer a question (state it, answer it, say what you will follow). Discharge summaries transfer custody (diagnoses as facts, changes to medications with reasons, pending results with owners, and instructions a patient can actually follow).

The assessment line, done and not done

Compare two versions of the same problem. Weak: 'AKI: monitor.' Strong: 'AKI, creatinine 180 from a baseline of 95, likely prerenal after three days of diarrhea; urine sodium pending. Held ramipril, one litre balanced crystalloid given, recheck creatinine at 16:00; if still rising, renal ultrasound and urine microscopy.' The strong version names the problem, the evidence, the leading mechanism with its uncertainty, and a plan that carries its own reassessment. That is a complete clinical thought, and it is exactly what the covering doctor at midnight needs.

Every problem line should let a stranger answer three questions: what do we think this is, how sure are we, and what happens next (including when we will know more).

Write for the reader at 03:00

The most important reader of your note has never met the patient and is being paged about them right now. Serve that reader: state diagnoses with their certainty ('confirmed', 'presumed', 'excluded'), attach reasons to medication changes ('furosemide held: creatinine rising'), and make the contingencies explicit ('transfuse below 70'). Avoid the two great rots: copy-forward, which lets dead problems and stale exam findings masquerade as today's truth, and chart lore, where an unverified label ('penicillin allergy', 'baseline confusion') replicates from note to note until no one remembers its source. Verify once, then write what you verified.