SUGGESTIONS FOR WRITING NOTES AT GPCHC
NextGen mechanics
Go to the SOAP tab
HPI
Double click in the HPI field
If a free text field opens, go ahead and start documenting.
If you see a template of check boxes, use the Additonal/Manage link in the left navigation pane to
edit the Reason for Visit. (NextGen will open a standardized template if it recognizes a common
complaint, e.g. “cough”. To override and generate a free text HPI field, add asterisks (“cough**”) or
additional descriptors.
If using WCC templates
Delete any headings/sections that you did not include in your encounter.
Edit/update any default findings that are not accurate.
Delete the suggested A/P at the end of the WCC template. (It can be copied/pasted into the A/P
section of the note but should not be left in the HPI.)
ROS
Open the Pediatric ROS and use radio buttons/check boxes to document only the most relevant
positive and negative details.
Exam
Open One Page Exam
Use check boxes in the main template to document straightforward findings.
To documented more detailed findings for a given system/area - click on the name of the
system/area. To generate a more readable note, use the free text Comments fields to document
details, rather than clicking through the check boxes.
Assessment and Plan
Click Assessment
Use the IMO search button to find and select an ICD-10 code
Click A/P Details
Enter information in the Provider Details plan.
Do not use the Impression, Patient Details… fields.
Content of notes
HPI
For medical students: Please add “Seen with [your name], Medical Student” at the top of the HPI
If you are working with a Fellow, please add, “Seen with [fellow’s name], Fellow” at the top of the HPI
Bullets are more readable, efficient, convincing than prose.
Note who was with the patient at the visit.
Describe concerns in the patient’s words.
Put information in chronological order.
Use number of days/weeks prior to the visit to quickly convey timeframe. (Phrases like “Last Saturday”,
or “On 3/12” require the reader to do some calculations.)
If this is a patient’s second/third/etc. visit for the same problem – or if the visit is a scheduled follow-up
visit- note that in the HPI.
If the patient has an underlying medical condition relevant to the current problem – mention that in the
HPI.
Assessment and Plan
Most readers look first at the A/P, then go back the HPI, exam, etc, if they need additional details.
Depending on the patient and reason for the visit, your assessment may include:
Dx/most likely Dx
Other diagnoses considered and why they are less likely
Assessment of overall clinical status. (For ongoing problems – better, same, worse)
Assessment of whether the patient has or is at risk for complications (e.g. dehydration)
Assessment of progress (for follow-up visits.)
Interpret and summarize essential data to support your assessment and plan. Don’t repeat details.
Cross-check the data and assessment sections of your note:
Make sure the data sections (HPI, exam, etc.) include all of the key details needed to back up your
assessment. (For example, don’t leave out exam findings related to hydration status if your assessment
includes “Patient is well-hydrated.”)
Make sure your assessment addresses all abnormal findings, problems, concerns mentioned in the body
of the note.
Words and phrases that demand action - or a deliberate explanation of why no action was taken:
Ill-appearing**
Lethargic**
Worsening
Severe
In distress
Having discomfort or pain (current/anticipated)
Patient/family is upset, worried, concerned, asking about…
** These suggest a need for urgent medical attention. If the patient is not being re-directed to the ER,
choose different words to describe.
In general, if you include the above terms/phrases in the body of your note, your assessment and plan must
acknowledge and address the findings or concerns they reflect.
(In particular, even if you are not worried about a particular issue, if you have documented that the patient is
worried/asking - address it explicitly in the assessment and plan.)
