How to Write a Physician Note

The purpose of a physician note

A physician note is not just a memory aid. It communicates clinical reasoning to other clinicians, supports continuity of care, records what happened, and helps justify diagnostic and management decisions.

Strong notes are concise but complete. They make it easy for another clinician to answer three questions: What is going on? Why do we think that? What should happen next?

• Tell the story in a clinically organized way.
• Include important positives and negatives.
• Separate patient-reported history from exam findings.
• Prioritize information that affects differential diagnosis, acuity, workup, treatment, or follow-up.
• Avoid unsupported conclusions. Show the evidence.

The note fields used in USCEAI

USCEAI uses a structured physician note so you can practice the same clinical categories repeatedly. The structure is intentionally explicit: it forces you to organize facts, not simply write a narrative paragraph.

HPI

History of Present Illness. The story of the chief complaint with timing, symptom features, associated symptoms, pertinent positives, pertinent negatives, and relevant context.

ROS

Review of Systems. A focused symptom review beyond the HPI, especially positives or negatives that matter to the differential.

Allergies

Medication, food, latex, contrast, or environmental allergies when relevant. Include reaction if known.

Medications

Current prescription medications, over-the-counter medications, supplements, recent antibiotics, anticoagulants, hormones, or other relevant treatments.

PMH

Past medical history, especially conditions that change risk, diagnosis, testing, or treatment.

PSH

Past surgical history, including procedures relevant to anatomy, complications, or current presentation.

SH

Social history, including tobacco, alcohol, recreational drugs, occupation, living situation, sexual history, travel, exposures, and safety when relevant.

FH

Family history, especially inherited risk or conditions relevant to the chief complaint.

VS

Vital signs: temperature, heart rate, blood pressure, respiratory rate, oxygen saturation, pain score, and sometimes weight or BMI.

Writing a strong HPI

The HPI is the center of the note. It should read like a compressed clinical story, not a list of every question you asked. Start with patient identity and chief complaint, then describe the symptom and its relevant context.

A strong HPI includes enough detail for the reader to understand acuity, likely causes, dangerous alternatives, and what information is still missing.

1. Start with age, relevant background, setting, and chief complaint.
2. Describe onset, location, duration, character, severity, timing, triggers, and relieving factors when applicable.
3. Add associated symptoms.
4. Add pertinent negatives that address dangerous or likely alternatives.
5. Add relevant risk factors, exposures, medications, pregnancy status when relevant, and prior similar episodes.
6. Close with care already tried or events leading to presentation.

42-year-old patient with hypertension presents with 3 hours of constant substernal chest pressure that began while climbing stairs and radiates to the left arm. Pain is associated with diaphoresis and nausea. Denies pleuritic pain, fever, cough, syncope, leg swelling, recent surgery, or prior similar episodes. Took no medications before arrival.

Writing ROS without over-documenting

ROS should not become a long generic checklist. In learning notes, it is better to document focused positives and negatives than to write a broad normal review unsupported by the interview.

If a symptom is central to the HPI, it can appear in the HPI. ROS can hold additional system-level symptoms that help frame the differential.

• Use focused language: denies fever, cough, dyspnea, hemoptysis, vomiting, dysuria, rash, or focal weakness when those negatives matter.
• Avoid documenting systems you did not ask about.
• Do not use all other systems negative unless that review was actually performed and appropriate in the setting.
• Put the most diagnostic symptoms in the HPI rather than burying them in ROS.

Documenting medical background

Background history is valuable when it changes pretest probability, safety, treatment, or follow-up. Not every remote fact deserves equal weight. A patient with abdominal pain and prior appendectomy, anticoagulant use, pregnancy possibility, inflammatory bowel disease, or alcohol use has details that may change the differential.

Writing the physical exam

In a simulated note, write the exam findings provided by the case that matter. In real practice, document what you actually examined. The most useful exam entries are specific and connected to the clinical question.

• VS: include abnormal vitals and interpret them when useful, such as febrile, tachycardic, hypoxic, hypertensive.
• General: document distress, toxicity, comfort, work of breathing, hydration, and mental status when relevant.
• HEENT: useful for headache, infection, dehydration, throat pain, vision complaints, trauma.
• Chest/Lungs: breath sounds, wheeze, crackles, work of breathing, tenderness.
• Heart: rate, rhythm, murmurs, perfusion, pulses, JVD when relevant.
• Abdomen: tenderness location, guarding, rebound, distension, bowel sounds, CVA tenderness.
• Extremities: edema, calf tenderness, pulses, deformity, range of motion.
• Neurologic: orientation, cranial nerves, strength, sensation, gait, focal deficits.
• Skin: rash, wounds, cellulitis, jaundice, diaphoresis, perfusion.

Differential diagnosis with supporting evidence

This is where many learners lose clarity. A differential is not a random list. It is a ranked set of plausible explanations. For USCEAI, each diagnosis should be paired with history and exam findings that support it.

A strong differential includes the leading diagnosis, serious alternatives that must not be missed, and other reasonable alternatives. It also acknowledges when evidence is incomplete.

1. Diagnosis 1: choose the most likely diagnosis based on the whole story.
2. History support: list symptoms, risk factors, timing, exposures, or negatives that make the diagnosis more likely.
3. Exam support: list exam or vital sign findings that support the diagnosis.
4. Diagnosis 2: choose a dangerous or plausible alternative.
5. Diagnosis 3: choose another reasonable alternative based on the presentation.
6. Avoid unsupported diagnoses that have no connection to the case facts.

Diagnosis #1: Acute coronary syndrome
History findings: exertional substernal pressure, radiation to left arm, nausea, diaphoresis, hypertension risk factor
Physical exam findings: tachycardia, uncomfortable appearance, no reproducible chest wall tenderness

Diagnostic workup

The workup section should answer: what tests or immediate steps would help confirm the diagnosis, rule out danger, risk stratify, or guide management? The appropriate workup depends on setting and acuity.

For USCEAI, you do not need to write a full order set. Write the high-yield diagnostics and urgent next steps that follow from your differential.

• Use tests that match the complaint and differential.
• Start with urgent tests for dangerous diagnoses when acuity is high.
• Include pregnancy testing when relevant before imaging or medication decisions.
• Include ECG, troponin, chest X-ray, CBC, CMP, urinalysis, lipase, imaging, cultures, or specialty consultation only when clinically connected.
• Avoid indiscriminate panels. More tests do not automatically make a better note.
• Include disposition thinking when relevant, such as ED transfer, admission, observation, outpatient follow-up, or return precautions.

Common documentation mistakes

• Writing a transcript instead of a clinical summary.
• Listing diagnoses without supporting evidence.
• Forgetting pertinent negatives that address dangerous alternatives.
• Putting exam findings in the HPI or history facts in the exam.
• Using vague words such as normal, bad, or fine without clinical specificity.
• Overusing abbreviations that could be misunderstood.
• Ignoring abnormal vital signs.
• Writing a workup that does not match the differential.
• Documenting information that was not obtained.
• Failing to include safety, urgency, or follow-up when the case requires it.

A complete mini-template

Use this as a mental template, not a rigid script. The best notes are tailored to the patient and setting.

HPI: [Age] with [relevant PMH] presents with [chief complaint] for [duration]. Symptoms began [onset/context] and are [character/severity/course]. Associated with [positives]. Denies [pertinent negatives]. Relevant risks/exposures include [details]. Tried [treatments] with [response].
ROS: Focused positives and negatives not already covered in HPI.
Allergies: [substance and reaction] or NKDA if confirmed.
Medications: [relevant current medications].
PMH/PSH/SH/FH: [only clinically relevant background].
VS: [temperature, HR, BP, RR, SpO2, pain if available].
Exam: [focused relevant findings by system].
Differential: [three diagnoses, each with supporting history and exam].
Workup: [tests, imaging, immediate steps, escalation, follow-up, or precautions appropriate to acuity].