Rayan FaroukWe explain often that documentation is crucial to maintaining the integrity of the doctor’s work. Among the many important forms of documentation are Clinical notes and Progress notes, these two help doctors keep track of their patients’ information over time. Even though they share a common goal of improving care, they serve distinct purposes and are used in different contexts.
Let’s start by explaining what Clinical notes and Progress notes are.
Clinical notes
These are your first notes before treating the patient. They are created at the beginning of the visit. They capture details about the patient’s condition, symptoms and the evaluation performed at that moment. In Balsam Medico, clinical notes or visit notes are broken down into 3 key components:
- Duration of Illness:
This section records how long the patient has been experiencing the symptoms or the pain to understand the timeline of the illness and whether it is acute, chronic, or recurring. For instance, writing “Pain has gotten worse over the past 3 days” or just simply “A month”.
- Chief complaint (C/O):
This is the primary reason for the patient’s visit, the symptom or concern that led them to find medical attention. It is typically recorded in the patient’s own words, such as “pain at upper left side”.
- Visit Clinical Notes:
These notes go beyond just listing the symptoms, you include the findings from the testing performed. They are detailed, providing a snapshot of the patient’s health status at that specific moment.
In essence, clinical notes document the patient’s current condition. They are usually focused on the current visit and are updated with each appointment.
Progress notes
Unlike clinical notes, progress notes are more dynamic and are used to record ongoing updates about a patient’s health over a specific treatment. They are used when a treatment is performed on a patient, where continuous monitoring of the treatment process is needed. They offer insights into how the patient is responding to treatment, whether their condition is improving and what the next steps in care should be. They could include the following:
- The symptoms and findings before starting the treatment.
- The treatment plan needed to be performed.
- How well the patient is responding to the treatment.
- Future recommended care plans such as follow-up visits.
Progress notes provide a longitudinal view of the patient’s health journey.
Their unity
Although they serve different purposes, they work together to provide a complete picture of the patient’s health over time. Clinical notes give the initial context: What symptoms did the patient present with? What are the findings? How long was the illness?
Progress notes then pick up where clinical notes leave off. They track the patient’s journey, allowing doctors to adjust treatment plans based on the patient’s evolving needs. Without clinical notes, progress notes would lack context. Without progress notes, clinical notes would remain isolated, not accounting for changes in the patient’s condition.
Balsam Medico
In the current visit page visible for the doctor, the first step is to write down the Clinical notes. The system will not allow you to add a treatment to the patient before adding the clinical notes. The reason is many doctors forget to mention the clinical notes and when the data is transferred to Nabidh, for instance, it could cause some major data violations and fines. So to reduce the potential fines, we created the warning to alert you to fill the clinical notes beforehand.
As for the progress notes, these are specific to each treatment. Once the clinical notes are added, the doctor can now add the desired treatment to the patient’s plan. After adding the treatment, you can click on its details button to view the progress notes page. Here, you can type down how the treatment is going and if there are any updates on the plan.
To learn more about the difference between them and where to find them in Balsam Medico, feel free to contact our Customer Success team. Our team is readily available to answer all your questions and inquiries.
In summary, clinical notes document the details of a single patient encounter, focusing on symptoms, diagnosis, and immediate treatments, while progress notes track the ongoing journey of the patient’s care, documenting their responses to treatment and any necessary adjustments to the care plan.
Learning the difference can help make accurate diagnoses, a great monitoring tool to track the effectiveness of the suggested treatment plan and for both legal and billing purposes, where the accurate and detailed documentation helps protect you and your clinic in cases of legal disputes and ensures that billing for services rendered is correct.
For anyone working in healthcare or clinic management, it’s important to emphasize the need for both types of documentation to work seamlessly together—ensuring that no piece of information about a patient’s health is ever overlooked.
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