Clinical Progress notes are difficult to write and read in large part due to the fact that the notes are written for a diverse audience.
When we write notes we write:
- For ourselves, to help us remember what our findings are and our treatment plan
- For our same discipline colleagues who provide coverage of care
- For nurses and others who follow instructions that we provide
For other disciplines who are caring for the same patient
- For billing staff in order to submit bills for payment
- For compliance staff to review our records for regulatory compliance
- For Risk Management staff to review records for liability risk
- For quality improvement staff who aggregate data and look at systems issues
- For attorneys who may be involved in lawsuits over care
- For the patient and family
- and in the VA, for Congressional Committees who provide oversight of care
Gator Psychiatry 