There’s more to a patient than vital signs, lab results, medical history, and medication allergies. While these data points are undoubtedly important, they don’t paint a full picture of a patient and their needs. Here’s a simple analogy: If the patient is a symphony, EMR data points are the sheet music—the notes, tempo, and key. But to truly experience the symphony, you need the performance—the atmosphere, the interpretation, and the human emotion. In healthcare, that’s where clinical listening comes in.
Clinical listening refers to the invaluable information captured in interactions between patient and provider and captured inside physician notes. When paired with structured data points, these unstructured notes can help care teams gain a better understanding of every patient.
We recently sat down with a Stanford clinician for an insightful conversation about the value of physician notes and the impact they can have on delivering high-quality patient care.
Q: What type of information goes into a physician’s note vs. structured fields in the EMR?
A: The structured fields in the EMR are great for capturing standardized, easy-to-track data—things like vital signs, lab results, medications, past medical/surgical history, and diagnosis codes. These fields make it easy to sort and retrieve information quickly.
But my notes? That’s where the real clinical picture takes shape. My notes tell the story behind the data. They include my clinical reasoning, the nuances of a patient’s symptoms, my thought process on a diagnosis, and details about their social or family history that could impact their care. Notes help me—and any other provider looking at the chart—to understand not just what is happening, but why.
Q: What information can only be put in notes?
A: Some details just don’t fit into structured fields. My notes capture those critical elements, like:
- Clinical reasoning – Why I’m considering one diagnosis over another, and what’s guiding my care plan and treatment choices.
- Patient-reported symptoms – Not just “pelvic pain,” for example, but how the patient describes it, what aggravates or relieves it, and how it impacts their daily life.
- Social and family history nuances – A patient might mention that she has no childcare and can’t attend follow-up appointments or is afraid of postoperative recovery after surgery due to caretaking responsibilities for a family member. That’s critical information that a checkbox can’t convey.
- Exam observations – A structured field may simply state “cervix: normal,” meaning there are no gross abnormalities (e.g., no obvious lesions, bleeding, or ulceration). But my note describes what I actually see—such as subtle changes in color or texture. If a cervix looks slightly different compared to prior exams—perhaps slightly more friable, or showing faint mosaicism—I may note it for future monitoring in my notes, as that could indicate an underlying issue even if what I am seeing doesn’t yet meet clear diagnostic criteria.
Q: Are there things you put in notes even if they’re available in structured fields? What and why?
A: Absolutely. I sometimes document medications and vital signs in my notes, even though they’re already in the structured fields. Why? Because context matters.
For example, a structured field might show that a patient’s blood pressure is 160/90, but my note explains why—maybe she just forgot to take her medication that morning, or she was anxious about being in the clinic. Similarly, I might list medications in my note to discuss side effects, adherence issues, or why I adjusted a dose. That added context can be crucial when making decisions down the road.
Q; How do physician notes inform diagnosis and treatment decisions?
A: Notes are where the puzzle pieces come together. When I’m trying to diagnose a patient, I’m not just looking at a blood test result—I’m reading prior notes to understand trends, understand past clinical reasoning, and gain insight into the patient’s history. Notes guide my treatment plans and ensure continuity of care.
They’re also a crucial communication tool. If another provider picks up my patient’s chart, I want them to immediately understand what’s been happening and why certain decisions were made, without having to piece together information from lab values, vitals, diagnoses, and medication lists.
Q: What might you miss if you don’t review notes?
A: A lot. If I don’t take the time to read prior notes, I could miss:
- Subtle but important symptoms that weren’t captured in structured fields.
- A colleague’s clinical reasoning—maybe another doctor was considering a rare condition, and I’d be missing that context.
- Key life details—such as a patient struggling with transportation or financial barriers that might affect adherence to treatment.
Skipping notes can lead to redundant testing, fragmented care, or even misdiagnosis.
Q: How do time constraints affect how and why you use notes?
A: Time is always a challenge. When doing my notes, it’s a balancing act—documenting enough to ensure quality care and smooth handoffs while managing the demands of a busy clinic or hospital shift. So we learn to be efficient and to the point in our notes.
However, when a physician has a particularly busy and demanding shift, writing/reviewing documentation can suffer. Sometimes, this means:
- Notes get rushed and lack detail.
- The physician might skim prior notes instead of reading them thoroughly.
- They may rely more on structured data to get background context since it’s quicker to scan.
Q: Can you provide a real-life example where another physician’s notes made a difference in patient care?
A: Absolutely. A small mention of symptoms, a past diagnosis, or even a treatment trial noted by another provider can influence current medical decisions. I once had a patient with persistent pelvic pain. Her ultrasound was normal, and standard treatments weren’t helping. Looking through her structured data—labs, imaging, vitals—nothing stood out. But when I dug into an old note from a previous visit, I saw that another physician had mentioned a history of endometriosis symptoms as a teenager, which the patient hadn’t brought up in our visit.
That note changed everything. It led me to consider endometriosis as a possible underlying cause, prompting me to adjust my evaluation and treatment plan. That detail, buried in a note, made all the difference in getting her the right care.
Q: Any final thoughts?
A: Structured data is essential for efficiency, but my notes bring the human judgement side of medicine into the record. They help me think critically, communicate my reasoning and key contextual information to other providers, and ultimately ensure my patients receive the best care possible.
Unite Genomics helps clinicians easily access the full set of medical records including clinical notes on a patient from other health systems. This is key in ensuring continuity of care. For research organizations, the platform further analyzes these notes for a deeper understanding of the disease journey, patient outcomes and physician decision making.
How Unite Helps.
Unite Genomics helps clinicians easily access the full set of medical records including clinical notes on a patient from other health systems. This is key in ensuring continuity of care. For research organizations, the platform further analyzes these notes for a deeper understanding of the disease journey, patient outcomes and physician decision making.
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