What does a visit note look like?

Reading Your Notes

What is a note?

Your medical record contains a lot of information about you, including laboratory results, medication lists, visit summaries, and X-ray reports. The medical record also includes notes. These notes are different from other types of information in the record. They document the conversation you had with your doctor, nurse or other health care professional and contain a summary of the most important information discussed. The notes are the story of your health care, connecting the other elements of your medical record.

Notes can look quite different, depending on who writes them and depending on the kind of health care visit. Sometimes they are brief descriptions, other times they include a complete accounting of the visit. These sample notes will give you a good idea of the kinds of information included in medical notes and why it might be helpful for you to access your own information between visits.

1. Orthopedic visit note

This patient visited an orthopedic specialist to talk about a hip replacement. In the note the doctor describes the visit and the patient’s symptoms. The doctor also outlines some next steps for the patient, including follow up appointments. The patient used the note to remind himself about the appointments he needs to make. He also shared the note with a family member who helps with his care and saved the note in a file at home in case he wants to get a second opinion.

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2. Mental health progress note

This patient has weekly therapy appointments with a social worker to talk about her feelings of depression and anxiety, which have become worse after a recent diagnosis of Parkinson’s Disease. In the note, the therapist describes the patient’s physical and mental health symptoms and outlines some of the coping strategies that were talked about in the therapy session. This patient was relieved to read that her therapist understands her condition. Parkinson’s affects her memory, so being able to look back at the notes helps her remember what she’s supposed to do between visits. Additionally, the patient could print the note and bring it to the doctor who prescribes her medications so that both members of her health care team are informed about her care.

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3. Chronic disease management note

This patient has type-1 diabetes and at least two other chronic health conditions. She takes several medications and uses her notes regularly to manage her health. She remembered a time when a medication dose appeared to be incorrect when she went to pick it up at the pharmacy. She looked up her notes to remember what her doctor said and was able to get the dosage corrected. Additionally, the endocrinologist involved in her diabetes management is not located at the same hospital where she receives the rest of her care, but she’s able to print the notes and share them. It’s important to her that her entire health care team has access to the same information. The notes have helped her feel more like an expert in her own conditions, and she says despite her complicated medical life, she feels healthy.

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4. Otolaryngology pre-surgery note

To prepare for surgery, this patient visited an otolaryngology (ear-nose-throat) specialist to determine if a breathing tube could be placed in her airway during surgery. The note summarizes the patient’s medical history and describes the examination that was performed. The note contains some difficult medical terminology, for example, otorrhea and choanae. The patient said that she did not understand those words, but still liked having the note. She looked up some terms on the Internet and wrote a list of questions in preparation for surgery. She was also able to share the note with her primary care doctor at a different institution.

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Questions you can ask yourself as you read your notes

• Are the lists – medications, symptoms, health problems – accurate?
• Does the information in the note reflect what was discussed during the visit, and did my doctor and I leave the appointment with the same understanding?
• Is this information something I might want to share with another member of my care team or my family?
• Is there anything I’m worried about that I want to clarify?
• Is there anything I don’t understand? Could I use some help with medical terms, a diagnosis, or the treatment recommendations?
• Is there any information, like symptoms or family history, I forgot to share at my appointment?
• Are there any inaccuracies in my record that should be fixed?