Accurate documentation is an essential element of safe and effective outpatient care, but creating electronic notes that are both thorough and defensible can be challenging.
Templates can save time, but they may omit critical details or introduce inconsistencies. Clinicians also need to balance legal considerations with capturing a patient’s story, clinical reasoning, and shared decision-making—all while managing busy clinic schedules.
On Healthcasts, clinicians across specialties shared their real-world strategies for outpatient note-taking. Their insights offer practical guidance on customizing templates, documenting thought processes, and maintaining accurate records, while navigating the competing pressures of efficiency and legal risk.
Do you have any tips for peers on how to write efficient electronic notes? Log in or sign up to read the full post, leave a comment, and see the Consensus.
Key takeaways about creating efficient electronic notes:
Dermatology
"1. Unfortunately, we now use templates that have both insignificant information and can leave information out. Medical legal concerns.
2. Add open-ended comments, adverse events discussed, including but not limited to etc."
Endocrinology/Diabetes
"1. If you did it, document it. If you didn't do it, don't document it.
2. Patient was given the opportunity to ask any additional questions, and these were addressed to the patient's satisfaction prior to the conclusion of the visit."
Internal Medicine
"1. Build a custom template or, in Epic (a smart note) that encompasses all that you want. That said, try as hard as possible to actually ask the questions it contains, and I understand we are doing our best.
2. End of note: I have answered to the best of my ability all questions asked. Any further questions will be addressed as they come up. (I know, excessive, but for this post, I think it covers nicely)."
Dermatology
"1. I make duplicate notes and am old-fashioned enough to write down pretty much everything that I put in an electronic note. I used to carry a pocket recorder in the old days, but now I simply dictate into my phone.
2. I find it more important not to say certain things or add certain notations than what is actually put in the note. Everything I add is short and to the point without adding anything that can be misconstrued or misinterpreted."
Family Practice
"1. Be careful not to use prefilled documentation to save time that contradicts the actions/diagnosis/assessments
2. Be thorough and honest in documenting the job and work that was done. Unfortunately, this takes time, which is at a premium for providers in the climate of healthcare."
Internal Medicine
"1. Basic templates for normal physical exam findings that you can change for abnormal is ok. I always free-type the HPI so that specific info about that patient can be entered. Avoid copy/paste at all costs.
2. As many others have noted, there are no specific words or documentation style that will protect you 100%. Keep documentation concise and truthful, and use your words to demonstrate your line of thinking and how it follows the standard of care. That’s the best you can do."
Dermatology
"1. We use templates but add in specific locations, descriptions, history, and past treatments. Include details such as dates and times of pertinent. Include follow-up recommendations.
2. Rx Drug Management for black box warnings, common AEs. We have a template if patients refuse a biopsy or refuse further treatment. A template for time and what was discussed if you bill for time. Document reason for deferred biopsy."
Internal Medicine
"1. You can create quick texts on documentation that you generally use and modify or customize accordingly. Now with AI, some practices are using summaries of the visit in EHR, and it is much more efficient and time-saving.
2. Documentation of options and pros and cons of treatment is necessary and should be able to defend your decision-making at the time of visit."
Internal Medicine
"1. A generic template works for me all the time. The chief complaint or complaints are on top in the order of priority; others are already populated in the template: allergies, social and past history, as well as meds. The exam is generic but modified based on what is important in the exam.
2. Verbage may include additional recommendations to follow. Differential dx discussed. Patient to call for any changes or symptoms."
Family Practice
"1. Try to make templates and dot phrases to justify time spent and things like that. Most of all, document your thought process, and that’s how charting matters nowadays. MDM.
2. Use dot phrases as best you can. Document everything."
Have you ever struggled to ensure all appointment details are properly added to a note? Share your approach and read all of the comments on the post on Healthcasts.