In medicine there are many different clinical notes that are written. They vary entirely upon the context of the situation (i.e. admission vs. progress note) as well as the specialty of the provider (medicine and surgery notes are NOT identical). While there are common elements to many notes (such as a chief complaint) the exact nature of the note is dictated by the audience of the note. As a medical student starting out this can be difficult to appreciate and master, so we have provided examples of different notes that are organized by specialty.
It is important to keep in mind that the below entries are just ONE example of how each type of note can be written. Always remember to tailor your note to the audience (i.e. the attending or resident who is going to be reading your note). Should your audience ask for more/less/different information do you best to accommodate them. Feel free to find notes that they have written and emulate their style.
Page Updated: 05.06.2016