Write notes people read.
Problem-based notes that lead with the plan, copy-forward traps, orders that can't be misread (Do Not Use list, PRN indications, hold parameters), two-source med rec, discharge summaries, and open notes.
Reviewed October 2026 · verify against current guidelines
The plan is the note.
Write for the reader who skims
Your attending, the night float, the consultant and the coder all jump to the same place: the assessment and plan. Write it by problem, most active first, and make it stand on its own. Everything above it exists to support it.
Daily progress note, in reading order
| One-liner | Age, key history, the admitting problem, hospital day, and the direction of travel. “HD 3, 68F with HFrEF admitted for volume overload, net −4 L, still on 2 L O2.” |
|---|---|
| Interval events | What happened overnight and what changed: new results, new symptoms, cross-cover calls, procedures. |
| Subjective | One or two lines in the patient's words. Pain, breathing, appetite, the thing they asked about. |
| Objective | Vitals as ranges and trends, I/O and weight when they matter, a focused exam you actually did today, labs that changed, new imaging. |
| Assessment & plan | Numbered by problem. Each one: what you think and why, then what you will do, when, and who owns it. |
| Disposition | Code status, expected discharge date, and what is blocking it. |
A strong problem entry
- Names a diagnosis or the best working one, not a lab value. “Hyponatremia, likely hypovolemic” beats “low Na.”
- States the trend and the evidence: better, worse, or unchanged, and why you think so.
- Gives a plan with a contingency: “Urine Na and osmolality sent before saline; isotonic saline started. If Na isn't rising tomorrow, reassess volume status and recheck urine studies.”
- Says what would change your mind.
The H&P is different
The admission H&P is the foundation everyone else builds on. Write the HPI as a timeline a stranger can follow. List home medications with doses, allergies with the actual reaction, and the social history that changes care: who lives with them, function, substance use. End with a prioritized problem list, each with its own assessment and plan.
Cut the noise. Own every word.
What to cut
- Lab dumps. Show what changed and what you are following, not every normal value.
- 48-hour vitals tables. Give the range and the trend.
- The full medication list. The MAR holds it; name only today's changes.
- Exam findings you did not re-examine today.
- Resolved problems. Collapse them to a single “resolved” line.
Safe copy-forward habits
- Copy the structure, never the findings.
- Rewrite interval events and the exam every day.
- Update each problem's status line and mark what changed (“HD 4: heparin stopped”).
- Read the whole note once, top to bottom, before you sign.
- Never alter a signed note. Add a dated addendum, labeled as a late entry.
Write orders a stranger can follow.
Every medication order: if it can be read two ways, it will be
| Drug | Generic name, spelled out. Never abbreviate a drug name. |
|---|---|
| Dose | Number plus unit. Always a leading zero (0.5 mg). Never a trailing zero (5 mg, not 5.0 mg). |
| Route & frequency | Written out where you free-text: “daily,” “every other day,” “subcutaneous.” |
| Indication on PRNs | Every PRN says what it is for: “ondansetron 4 mg IV every 8 hours as needed for nausea.” Two PRNs for the same symptom need a rule for which comes first. |
| Hold parameters | Numbers, not adjectives: “Hold metoprolol for SBP less than 100 or HR less than 55,” not “hold for low BP.” |
| Weight-based doses | State the dosing weight, its source, and the per-kg dose: “enoxaparin 1 mg/kg = 80 mg SUBQ every 12 hours (measured weight 80 kg).” Check kg versus lb. |
| Verbal & telephone orders | Only when you truly cannot enter it yourself, and per policy. The nurse reads back the full order; you confirm it, then sign it promptly. |
Joint Commission official “Do Not Use” list
| U, u | Write “unit.” Mistaken for 0, 4 or “cc.” |
|---|---|
| IU | Write “International Unit.” Mistaken for IV or 10. |
| Q.D., QD, q.d., qd | Write “daily.” |
| Q.O.D., QOD, q.o.d., qod | Write “every other day.” |
| Trailing zero (X.0 mg) | Write X mg. A missed decimal point is a tenfold overdose. |
| No leading zero (.X mg) | Write 0.X mg. |
| MS, MSO4, MgSO4 | Write “morphine sulfate” or “magnesium sulfate.” |
The list applies to all orders and medication-related documentation that is handwritten, including free-text computer entry, or on preprinted forms. A trailing zero is allowed only to show precision of a reported value (a lab result, a lesion size, a catheter size), never in a medication order. ISMP's broader list adds: write mL, not cc; mcg, not µg; SUBQ, not SC or SQ; “intranasal,” not IN; “discharge” or “discontinue,” never D/C; and “less than” or “more than,” never the symbols.
Call pharmacy before you sign when
- You need a renal or hepatic dose adjustment and are not sure of it.
- The drug runs on levels: vancomycin, aminoglycosides, warfarin, digoxin, many antiepileptics.
- You are starting, switching or bridging an anticoagulant.
- It is an insulin or heparin infusion, chemotherapy, or an opioid in an opioid-naive patient.
- An interaction alert fires and you do not understand it. Do not click through.
- The patient is at an extreme of weight or age, or it is a drug you have never ordered.
Reconcile from two sources, not one.
What the standard requires
Medication reconciliation compares what the patient actually takes with what you are ordering, at admission, transfer and discharge, and resolves every difference. For hospitals, the Joint Commission's National Performance Goals (effective January 2026) carry this as NPG.14.05.01; it was NPSG.03.06.01, which is still the label in some programs such as ambulatory care. It requires obtaining current medications, including as-needed ones, comparing them with hospital orders to resolve discrepancies (omissions, duplications, contraindications, unclear information, changes), and giving the patient a written list at discharge.
Sources for the best possible medication history
| Patient or caregiver | Open-ended: “Walk me through what you take in the morning.” Then ask about inhalers, eye drops, creams, patches, injectables, over-the-counter drugs, vitamins, supplements and herbals. |
|---|---|
| Pill bottles | Ask family to bring them in. Read the label, the dose and the fill date. |
| Pharmacy fill history | External prescription history in the EHR, or call the pharmacy. It shows what was filled, not what was taken. |
| Clinic list & last discharge summary | The PCP's list and the most recent discharge medications. |
| Facility MAR | For patients from a nursing facility, the MAR is often the most reliable list, but still confirm it. |
At every transition, decide every medication
- Continue as is.
- Hold, with the reason and the trigger to restart.
- Change the dose, with the reason.
- Stop, with the reason.
- Start new, with the indication and duration.
Write the discharge summary for the PCP.
Why it matters
In Kripalani's 2007 systematic review, the discharge summary was available at the first post-discharge visit only 12–34% of the time, direct hospital physicians-to-PCP communication happened in 3–20% of discharges, and test results pending at discharge were missing from 65% of summaries. Finish it on the day of discharge and put the essentials where a busy reader will find them.
What the PCP needs
| Diagnoses | Principal and secondary. Mark what resolved and what is still active. |
|---|---|
| Hospital course | Brief and by problem. Key procedures and results, not a day-by-day diary. |
| Medication changes | Every new, stopped and changed drug, each with its reason: “Lisinopril held for AKI; recheck BMP in 1 week and restart if creatinine is back to baseline.” |
| Pending results | The test, who will follow it up, and how the patient will hear the result. |
| Follow-up | Appointments, labs and imaging, with dates and what each is for. |
| Key data | Discharge vitals, weight (heart failure), labs and baselines the next clinician will compare against. |
| Goals & code status | Plus what the patient and family were told. |
Assume the patient reads it first.
The rule
Under the 21st Century Cures Act information blocking rules, applicable since April 5, 2021, clinicians and hospitals may not unreasonably interfere with patients' access to their electronic health information. The scope was limited to a defined core data set until October 5, 2022, and has covered the full designated record set since then. Federal guidance (updated September 12, 2025) says a policy that delays releasing results “for any period of time” so the ordering clinician can review them first is likely interference. Delaying at the patient's own request is generally acceptable. Narrow exceptions, such as Preventing Harm and Privacy, have specific conditions. In practice, your note can reach the portal before rounds end.
Write for two readers
- Describe, don't label: “drinks 6 beers daily,” not “alcoholic”; “declined insulin,” not “refused” or “noncompliant.”
- Quote the patient for symptoms and goals.
- Spell out abbreviations that mean something else to a patient (“SOB”).
- Keep disagreements with colleagues out of the chart. Have the conversation instead.
- Before you document a frightening new diagnosis or differential, talk to the patient, or plan to soon. They may read it tonight.
- Clear, not softened. Do not hide the medicine; accurate, specific and respectful serves both readers.
Educational reference only — not medical advice. Verify against local protocol.
Sources
Verify against current guidelines and local protocol before acting.
- The Joint Commission. Official “Do Not Use” List. https://www.jointcommission.org/-/media/tjc/documents/resources/patient-safety-topics/patient-safety/do_not_use_list_9_14_18.pdf; and Facts about the Official “Do Not Use” List (fact sheet; list applies to all orders and medication-related documentation that is handwritten, including free-text computer entry, or on preprinted forms).
- Institute for Safe Medication Practices. ISMP List of Error-Prone Abbreviations, Symbols, and Dose Designations. 2024. ismp.org.
- The Joint Commission. National Performance Goals, Hospital Program, effective January 2026. NPG.14.05.01: The hospital maintains and communicates accurate patient medication information.
- The Joint Commission. National Patient Safety Goals, Ambulatory Health Care Program, effective January 2026. NPSG.03.06.01 (medication reconciliation).
- Agency for Healthcare Research and Quality. Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation. ahrq.gov (reviewed April 2023).
- Kripalani S, LeFevre F, Phillips CO, et al. Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care. JAMA 2007;297(8):831-41. doi:10.1001/jama.297.8.831.
- ASTP/ONC, HealthIT.gov. Information blocking FAQs: limited EHI scope April 5, 2021 through October 5, 2022; delays in releasing EHI; patient-requested delays (updated September 12, 2025).
- ASTP/ONC, HealthIT.gov. Information Blocking Exceptions fact sheet (45 CFR Part 171), including the Preventing Harm and Privacy exceptions.
- Conventions vary by hospital and EHR. Follow your institution's order and documentation policies.