ABSTRACT
As we have discussed in the previous chapter, there are many components to a progress note. Although it is obvious that not every patient encounter requires extensive documentation of every section, physicians should always err on the side of overdocumentation versus underdocumentation. Omit sections only when you are confident that they will have no bearing on the patient’s treatment. Thorough documentation will be extremely unlikely to be detrimental to you – with the exception of the additional cost of the medical transcription and the time involved in documenting.
