Gilbert I. Martin, MD

The daily progress note has many components, and multiple publications have documented the medical-legal aspects of complete reporting. Initially, progress notes were a means to promote communication between physicians and other caregivers. However, as time has progressed, the daily note is often utilized for what it does not include when reviewed from a legal prospective. 

It is clear that alteration or tampering with the medical record destroys the credibility of a witness, and juries can believe that there is an attempt to “hide the truth.” As we have progressed from the handwritten, often incomplete progress note to a more consistent, detailed iteration, the focus of the patient and the observations and plans is sometimes lost. 

In addition, the electronic medical record allows for the repopulation of notes, and despite good intentions, the different portions of the daily progress note are frequently repeated and not updated. Therefore, the reader can be left in limbo spending more time in the past than in the present and future. 

There are legal implications, as well as the repetition of data becomes tedious. I can remember an interaction I experienced as a percipient witness many years ago. I was explaining my progress notes, and the plaintiff’s attorney had me read out loud to the court what I had written concerning the baby. 

I read to the court, “the baby is resting in the mother’s arms.” The plaintiff’s attorney then asked me to read the initial statement in the following day’s progress note. 

I read to the court, “the baby is resting in the mother’s arms.” The plaintiff’s attorney had me read three or four more initial lines in the progress notes, which all started the same way. 

Finally, the attorney came close to me and said, “Dr. Martin, don’t you think that the mother’s arms were getting tired after several days of holding the baby?” There was that uncomfortable rustling and giggling sound from the jury as it was evident that the notes were self-populated and not carefully reviewed and updated. 

Think about the pros and cons of computerized progress notes. The notes are often redundant. If the copy-and-paste option is utilized, the same information appears daily. 

What then represents the perfect written note in a patient’s chart? The characteristics remain consistent. The verbiage must be clear, well-organized, and incredibly focused. Our notes become obfuscated if we approach this documentation with a defensive attitude. 

If the daily progress note is constructed as a method of communication between all caregivers, the format should be consistent and organized and state the change in the baby’s condition or if there is recent laboratory information, if applicable. 

In 1994 I penned an editorial entitled “The Perfect Note.” I compared the presentation of this perfect note to musical composers (Vivaldi, Mozart, Beethoven, Lloyd Weber, and Elton John). Like a medical progress note, the composer’s score must be “clear, organized, directed, and even repetitious). 

Progress notes have now progressed to being an important “legal” document. Attorneys who do not have a medical background concentrate on the words rather than the meaning as represented by the caregiver. If all hospitals and physicians utilized a consistent format, data collection would improve, and these statistical models would positively affect healthcare. 

The daily progress note needs to be comprehensive, well organized, functional, accurate, and especially practical for all healthcare team members. 

To me, the perfect note is the hollow, clear, haunting, consistent “A” that comes from the oboe as the orchestra members tune their instruments.