HCA 310 Module 3 Documenting an Exam and Diagnosis Example

Writing the Visit Into the Record: Documenting an Exam and Diagnosis Electronically

Student Name

Health Care Administration Program, Aspen University

HCA 310: HIPAA and Electronic Health Records

Instructor Name

Month Day, Year

Writing the Visit Into the Record: Documenting an Exam and Diagnosis Electronically

The visit note is the core of the electronic record. It tells the next clinician what happened, supports the diagnosis and billing codes and serves as the legal account of care. Electronic records offer templates, structured fields and shortcuts that can make notes faster and more complete, or longer and less useful. This paper presents a composite electronic note for an orthopedic visit in SOAP format and explains how each part is documented.

The SOAP Format

SOAP stands for subjective, objective, assessment and plan. Subjective information is what the patient reports. Objective information is what the clinician observes and measures. The assessment states the clinician's conclusions, usually diagnoses. The plan lists what will be done. Most electronic record templates follow this order, even when they label sections differently.

Subjective

Ms. V., 58, presents with right knee pain for four months, worse with stairs and after sitting, with morning stiffness lasting about 20 minutes. No injury. Pain 6 of 10 at worst. Ibuprofen helps partly. No locking or giving way. Medications: lisinopril 10 mg daily, ibuprofen as needed. Allergies: penicillin, rash. Works as a librarian; walks 20 minutes most days but has cut back.

Objective

Height 5 ft 5 in, weight 176 lb, blood pressure 132/82. Right knee: mild effusion, crepitus with motion, tenderness along the inner joint line, range of motion 0 to 115 degrees, stable ligaments, negative meniscal tests. Left knee: normal. X-rays of both knees, standing: right knee medial joint space narrowing with small bony spurs; left knee normal.

Assessment

1. Primary osteoarthritis, right knee. 2. Hypertension, controlled, managed by primary care. The first diagnosis is specific to side and type, because the official coding guidelines ask coders to capture as much detail as the note supports and nothing it does not (Centers for Medicare & Medicaid Services & National Center for Health Statistics, 2025). Laterality, right versus left, is part of the diagnosis code in many orthopedic conditions.

Plan

Physical therapy for quadriceps strengthening, twice a week for six weeks. Continue ibuprofen with food, no more than the labeled dose, given her blood pressure; recheck blood pressure with primary care. Weight loss discussed. Corticosteroid injection offered; patient prefers to try therapy first. Follow up in eight weeks, sooner if locking or swelling worsens.

Templates

The practice's knee template offers checkboxes for common findings, such as effusion and crepitus, and drop-down lists for range of motion. These speed documentation and make findings searchable. The risk is that templates default to normal findings that the clinician did not actually examine. The practice set its template defaults to blank so that each finding must be entered.

Structured Fields and Free Text

Structured fields, such as blood pressure, medications and diagnoses, allow the record to run alerts, reports and quality measures. Free text captures the patient's story and the clinician's reasoning, which checkboxes cannot. Good notes combine both: structured data for what must be counted and free text for what must be understood.

The Copy-Forward Problem

Electronic records make it easy to copy text from earlier notes. In a study of more than 104 million notes, 50.1% of all text was duplicated from earlier text, and the share rose from 33.0% in 2015 to 54.2% in 2020 (Steinkamp et al., 2022). Copied text can carry forward outdated information, such as a medication the patient stopped, and makes notes harder to read. The practice allows copying only for stable history sections and requires review of any copied text.

Signing and Timeliness

A note is not complete until the clinician signs it electronically, which locks it and records the time. The practice expects notes signed within 24 hours of the visit. Late notes delay billing and leave the next clinician without information. The record shows unsigned notes on each clinician's work list.

Correcting a Note

Once signed, a note cannot be edited silently. If Ms. V.'s surgeon later realizes the range of motion was recorded incorrectly, he adds an addendum with the date, time and correction, and the original remains visible. This protects the integrity of the legal record and shows who changed what and when.

The Administrative View

Administrative staff do not write clinical notes, but they depend on them. Coders read the assessment and plan to assign codes, referral coordinators need the plan to arrange therapy, and billing staff need signed notes to release claims. A clear, timely note makes every downstream task easier.

Privacy of the Note

The note contains sensitive information and is visible to many users. Access is role-based, and the audit log records every viewer. Patients can read their own notes through the portal, which encourages clinicians to write clearly and respectfully, and the practice's notice of privacy practices tells them how the note may be used and shared (U.S. Department of Health and Human Services, 2022).

Documentation by Others

Several people contribute to the note. The medical assistant enters vital signs, medications and allergies; the surgeon documents history, examination, assessment and plan. Each entry is stamped with the author's name and time. When scribes enter information on the surgeon's behalf, the record identifies the scribe, and the surgeon reviews and signs the note, remaining responsible for its content.

Documenting Patient Education

The plan section also records what the patient was told and understood, such as the risks of anti-inflammatory medicine with her blood pressure medicine and her choice to delay an injection. Documenting shared decisions protects both patient and clinician and helps the next clinician continue the conversation.

Notes for Other Readers

Notes are read by referring physicians, therapists, insurers, auditors and patients. Clear headings, a concise assessment and a plan written in full sentences help all of them. Abbreviations that could be misread are avoided, and the surgeon writes the plan so a therapist can act on it without calling.

Timeliness and Billing

Unsigned or incomplete notes hold up claims because coders cannot code from drafts. The billing office tracks notes awaiting signature and reminds clinicians daily, so revenue is not delayed by documentation backlogs.

Conclusion

An electronic visit note in SOAP form records what the patient reported, what the clinician found, what the clinician concluded and what will happen next. Templates and structured fields help when used deliberately, but copied text and default findings can undermine accuracy. Specific diagnoses, timely signing and transparent corrections make the note a reliable record for care, coding and the law.

References

Centers for Medicare & Medicaid Services & National Center for Health Statistics. (2025). ICD-10-CM official guidelines for coding and reporting FY 2026. https://www.cms.gov/medicare/coding-billing/icd-10-codes

Steinkamp, J., Kantrowitz, J. J., & Airan-Javia, S. (2022). Prevalence and sources of duplicate information in the electronic medical record. JAMA Network Open, 5(9), Article e2233348. https://doi.org/10.1001/jamanetworkopen.2022.33348

U.S. Department of Health and Human Services. (2022). Summary of the HIPAA privacy rule. https://www.hhs.gov/hipaa/for-professionals/privacy/laws-regulations/index.html