As you document your assessment and plan, TALK TO YOURSELF! Here is one time where talking to yourself is not considered insane! Tell yourself what you are thinking in the encounter (“I’m not sure exactly what is causing her fatigue, but either sleep apnea and/or depression is highly likely”). Tell yourself what are some of the things that you want to “rule out” in the future if your current work-up comes back negative (“Consider ordering an EGD if cardiac work-up comes back negative”). Tell yourself what your treatment plan is over the next few appointments (“If patient does not improve with home stretching and NSAIDs, consider starting physical therapy next visit”). Tell yourself the plan for the followup visit (“Consider repeating Chem 7 next visit since we increased her dose of HCTZ”). Tell yourself why you don’t think certain dangerous things are in the differential (“I don’t think that her chest pain is cardiac in nature since there is a strong correlation with spicy foods and laying down at night”). Tell yourself interesting facts about the patient (“She is going with her sister to Maui next week.”)
All these little tidbits are an important part of the “narrative” aspect of good physician documentation. As medicine slowly transitions to EMR, don’t forget this “narrative” aspect of documentation. It is important for medical-legal reasons. It is important for simply being a good doctor!