What Makes a Good Clinical Note?
A useful AMA STEPS Forward resource for anyone thinking about clinical documentation and note bloat.
Physicians from the University of Wisconsin discuss how they redesigned clinical notes by asking a simple question: what actually needs to be here? Their work focused on reducing copied and unnecessary content, making clinical reasoning easier to find, and reconsidering whether the traditional SOAP format is always the most useful approach.
As AI scribes make it increasingly easy to generate more documentation, this is a good reminder that more text does not necessarily mean a better note.
Worth a listen. Write Shorter Notes: Implementing a Standardized Progress Note Template via AMA.
Family Medicine Residency Site: Abbotsford-Mission 