Here are some guidelines to help you capture all critical details during an encounter in the Results section of your note.
Best Practice |
Avoid |
Better |
1. Specify results by name |
“Your labs look fine.” |
“Your triglycerides were within normal range.” |
2. Say both the month and day, if known |
“In March…” (may default to 3/1) |
“On March 5th…” |
3. If listing multiple values for the same labs, specify the date for each |
“Your last two A1c values were 6.7 and 6.3…” |
“On June 11th your A1c was 6.7, on August 6th your A1c was 6.3…” |