Documentation and Handover

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Learning Objectives:

By the end of this post you will be able to:

Write a problem-based plan in which every active problem carries a status and a rationale.
Distinguish what may be carried forward from what must be written fresh each day.
Produce a discharge summary that communicates medication changes and pending results to whoever takes over.

Before Day One

Start Here

What you need to know before seeing your first patient on the wards

Estimated read time: 3 minutes

What the note is for: someone who does not know your patient will read it — the resident covering tonight, the consultant, the family doctor after discharge. The test set by the Canadian Medical Protective Association (CMPA): a good note lets a later reader “place themselves in your shoes.”
What it has to carry: the problems active today, the results that came back, the results you are still waiting for, and a plan that says how it differs from yesterday’s — the four things that separate a note which moves care forward from one that only records it (Cadieux & Goldszmidt, Medical Education 2017).
Before you write: read the overnight nursing note, the vital signs, the new results, and which medications were held on admission.
What every problem needs: a status word — improving, worsening, stable, resolved — and a reason for it. “Pneumonia, improving. Fever curve downtrending.” That is the whole bar (Bierman et al, Teaching and Learning in Medicine 2017). “Acute” and “chronic” are not status words.
The mistake to avoid: writing for yourself. The better you know a patient, the less you feel the need to write down — and whoever covers tonight has never met them. Past history can be copied; the subjective, exam, results and assessment are claims about today.
When to write it: before running the list, when the team goes through every patient together. A note filed at 18:00 helped nobody.

Going Deeper

On the Wards

Four templates and the evidence behind them: a progress-note checklist, a problem written two ways, a sample discharge summary, and a handover structure

Estimated read time: 7 minutes

Jump to: Who Reads It · The Progress Note · Discharge Summaries · The Legal Minimum · Handover

1. Who Reads It

Day 1 asked you to become the person who knows your patients best. The note is where that knowledge either survives or does not. In observations of 17 junior trainees on Canadian teaching units, one attending described the gap: “they seem to have a really good grasp of the patient… and you look at their note and go, well where is all that?” (Cadieux & Goldszmidt, Medical Education 2017)

Write for the person who does not know your patient — and that list includes the supervisor filling in your assessment form. When the same student notes were scored by reviewers who had never met the patient and by the ward team who had, the strangers scored them about 15 percentage points lower (Kim et al, Cureus 2022). It is also assessed in its own right: from your first months, the milestone asks you to convey “clinical reasoning and the rationale for decisions” (Royal College of Physicians and Surgeons of Canada, Internal Medicine 2021), and by the time you are a general internal medicine resident, documenting clinical encounters is an entrustable professional activity of its own (Royal College of Physicians and Surgeons of Canada, GIM Core EPA #9).

2. The Progress Note

Ward notes are written in SOAP order, and the four letters are the four parts of every note you will write: Subjective, what the patient and the nurses report since yesterday; Objective, the vital signs, examination and new results; Assessment, what you think is going on and why; and Plan, what you are doing about it. Some hospitals label the assessment a summary statement or problem list, but the order is the same everywhere.

One problem, two ways

Recorded

“Pneumonia. Continue ceftriaxone.”

Communicated

“Pneumonia, improving — fever curve downtrending, off oxygen since this morning. Day 3 of ceftriaxone; will step down to oral amoxicillin-clavulanate once afebrile 24 hours. Blood cultures still pending.”

Two sentences longer, and it adds a status, a reason, the condition that will change the plan, and the result somebody has to chase.

The scoring form used to give internal medicine residents feedback on their progress notes, with the points as a reviewer would award them. Run your own note through it before rounds.

Section	What earns the point	Points
Subjective	Pertinent positive and negative symptoms addressed — or their absence documented	+1
	Events of the last 24 hours updated, or “no overnight events” stated	+1
Objective	Vital signs, including intake/output or trends, unless not pertinent	+1
	Physical examination documented	+1
	Pertinent positive and/or negative findings in at least one organ system	+1
	Labs and diagnostic data updated	+1
Summary and assessment	Summary statement combining history, examination and data with an updated diagnosis and working differential	+2
	Summary statement missing some of those elements	+1
	“A synopsis, restated HPI, and/or hospital course”	0
	Hospital problems identified	+1
	Semantic qualifiers on the primary problem — improving, stable, worsening	+1
	Clinical reasoning supporting the cause or differential of the primary problem	+1
Plan	A plan for each problem	+1
	Clinical reasoning supporting the treatment or diagnostic approach	+1
	Evidence or a guideline named in support of the approach	+1
Copy-forward penalties	Subjective contains outdated, inaccurate or distracting carried-forward text	−1
	Examination is mostly carried forward, or an unedited template	−1
	Labs or imaging autopopulated, or mostly carried forward	−1
	Assessment and plan contain outdated, inaccurate or mostly carried-forward text	−1
	Carrying forward another author’s text	−2
Timeliness	Filed before 11:00 — before running the list	+1
	Filed before 15:00	0
	Filed after 15:00	−1

Two rules govern the total. You need at least one point in each of the four SOAP sections above — subjective, objective, assessment, plan; the penalties and the timeliness mark sit outside them. Score zero in any one of the four and the whole note scores zero, which the form calls a critical deficiency (Richardson et al, Medical Science Educator 2022). The copy-forward penalties are where most points are quietly lost — worth knowing that in a typical resident progress note, about 11.8% of the text was typed that day and 51.4% was carried forward (Wang et al, JAMA Internal Medicine 2017).

Adapted from the Internal Medicine Progress Note Evaluation Form in Richardson KM, Cristiano JA, Schafer KR, Shen E, Burns CA. Writing Is Thinking: Implementation and Evaluation of an Internal Medicine Residency Clinical Reasoning and Documentation Curriculum. Medical Science Educator 2022;32(4):773–777. doi:10.1007/s40670-022-01570-5

When you cannot name the cause yet

Write it in three parts — problem, etiology, plan. “#4. Acute kidney injury, worsening — creatinine 180, up from 95 on admission. Pre-renal from diuresis versus contrast nephropathy after Tuesday’s CT. Urine sodium and osmolality sent, furosemide held.” A problem you cannot name is still a problem you can document. What the scoring form will not accept is a lab value with an order under it: problems have to be written as diagnoses, or carry a differential beneath them (Bierman et al, Teaching and Learning in Medicine 2017).

Keep the problem list honest. The temptation is to drop a problem the day it goes quiet. One resident explained a note that had done exactly that: “I didn’t even put CHF… because I knew all those medications were on hold… I didn’t do hyponatraemia or hypokalaemia because those were all normal for right now” (Cadieux & Goldszmidt, Medical Education 2017). A held medication and a normalized sodium are reasons to keep watching, not to stop writing.

Then the mechanics. Keep the plan issue-based, move resolved issues to the bottom rather than deleting them, and write dates rather than days — “biopsy performed February 1, 2026”, not “biopsy performed today”, which then reads “today” for a week. Record the standing items for every patient: diet, activity, DVT prophylaxis, medication reconciliation, disposition, code status.

Then read other people’s notes. Your senior residents’ notes and your attendings’ attestations are the most accessible teaching on the ward and nobody assigns them. Read them for the phrasing you want to borrow and for how an experienced clinician commits reasoning to the chart — what they choose to justify, what they leave out, and how they say a thing is uncertain without saying nothing.

3. Discharge Summaries

Completing every section is the easy half and most residents manage it — of 90 summaries scored at a Canadian center almost every required item was present, yet about a third of the medication details in them were wrong (Legault et al, BMC Medical Education 2012), which matters because the discharge prescription is where Canadian community pharmacies trace medication incidents back to (Cao, Ng & Ho, ISMP Canada, Pharmacy Connection 2015).

Where summaries fail	What the evidence shows	What to do about it
The medication list	Inaccurate in 35.7% of the summaries that had one	Reconcile against the administration record, not the admission note. Stop hospital-only medications. Ask a pharmacist early.
Why a medication changed	Missing in 15.9%, wrong in 37.7% when present	One clause per change: what it was, what it is now, why. The item family physicians most need and least often get.
Pending results	Absent from 65% of summaries	Name the test, mark it (ordered), and say who acts on it — even if you expect it to be normal. This is the sentence the Royal College calls anticipatory guidance, and the one most often missing.
The follow-up plan	Rated insufficient by family physicians in 27.7%	Who is seeing the patient, when, and what they are asked to do — not “follow up with GP”. Route it to their specialists with the clinic’s phone number.
Anything for the patient	Documented in only 8–10%	Their own section, in plain language, with the red flags that should bring them back and a number to call if nobody contacts them.

Medication and follow-up figures from Legault et al, BMC Medical Education 2012; pending-result and patient-counselling figures from Kripalani et al, JAMA 2007.

If you have followed a patient for two days, start the summary. Update the hospital course issue by issue while you still remember why. One assembled at 17:00 on discharge day from a week of progress notes is where the inaccuracies come from.

Presenting complaints

Mr. Patient presented with a 4-day history of shortness of breath, productive cough, and progressive lower extremity edema, in the context of a recent sick contact. In the Emergency Department, he was febrile and hypoxic requiring supplemental oxygen; initial investigations were notable for an elevated BNP and pulmonary edema with consolidation on chest x-ray. For further work-up and management of acute decompensated heart failure, he was admitted under Medicine.

Course in hospital

#. Acute decompensated heart failure: The etiology was suspected to be infectious, triggered by pneumonia (see below). He was started on furosemide 40 mg IV daily, then transitioned to furosemide 40 mg PO BID. An inpatient TTE revealed an LVEF of 38%. He was started on all four pillars of goal-directed medical therapy in hospital. His BNP at the time of discharge was #. His dry weight is estimated to be #kg. He was referred to the HF Pathway, and he will be followed by Dr. Heart as an outpatient.

#. Community acquired pneumonia: Respiratory swabs, including COVID-19 swabs, were negative. In hospital, he was started on ceftriaxone IV and transitioned to amoxicillin-clavulanate PO. He will complete a total 5-day course (end date March 5, 2026) before reassessment with a repeat chest x-ray at our Post-Discharge Clinic. By the time of discharge, he was afebrile with normal saturations on room air.

Medications

Started in hospital: sacubitril/valsartan (Entresto) 24/26 mg PO BID; spironolactone 12.5 mg PO daily; metoprolol succinate 12.5 mg PO daily; empagliflozin 10 mg PO daily; furosemide 40 mg PO BID.
Continued unchanged: [home medications].
Stopped at discharge: hospital-only medications (as-needed analgesia, thromboprophylaxis). Amoxicillin-clavulanate 875 mg PO BID — stop date March 5, 2026.

Ask your pharmacy colleagues for help early, and give a stop date for anything not meant to continue indefinitely.

Follow-up instructions for medical professionals

Dear Dr. GP and Dr. Heart, your patient was admitted for acute decompensated heart failure, provoked by community acquired pneumonia. He diuresed well and by discharge, he was euvolemic on furosemide 40 mg PO BID. His dry weight is estimated to be #kg. As part of goal-directed medical therapy, he was also started on sacubitril/valsartan (Entresto) 24/26 mg BID, spironolactone 12.5 mg daily, metoprolol succinate 12.5 mg daily, and empagliflozin 10 mg daily. Please monitor his blood pressure, electrolytes, and renal function, thank you.

Dear Post-Discharge Clinic, Mr. Patient was admitted for acute decompensated heart failure secondary to pneumonia. He was started on goal-directed medical therapy and he will complete a 5-day course of antibiotics. Please follow up on his electrolytes/creatinine (ordered) and repeat chest x-ray (ordered), thank you.

Follow-up instructions for patients

Dear Mr. Patient, you were admitted for heart failure and lung infection. You were started on antibiotics in hospital. Please continue taking amoxicillin-clavulanate until March 5, 2026, inclusive. Please note that you will be seen in-person at our Post-Discharge Clinic with a repeat chest x-ray; we will call you with appointment details. In the interim, please take your other medications as prescribed, including the newly added medications (Entresto, spironolactone, metoprolol succinate, empagliflozin, furosemide) for your heart. For your heart failure, you have been referred to Dr. Heart. Their clinic will call you with appointment details but if you do not hear from them in 2-3 weeks, please feel free to reach them at #.

Please return to the Emergency Department if you experience new chest pain, recurrent shortness of breath, lightheadedness, persistent vomiting or diarrhea, or new fevers.

4. The Legal Minimum

All of it from the CMPA’s guidance on documentation and record keeping.

Write it when it happens. Contemporaneous notes are more credible than reconstructed ones, and a late entry should be labelled as one.
Correct by addendum, never by deletion. On paper, one line through the error, initialled and dated, original still legible. Electronically, an addendum stating what changed and why. The audit trail records every edit regardless. And “never make a correction or change an entry after learning of a complaint or legal action”.
Standard abbreviations only. Your own shorthand is illegible to the person the note exists for.
Your login is you. Never use anyone else’s, never lend yours, and access records only within your circle of care.
Say why you overrode the alert. If you dismiss a decision-support warning, the reasoning belongs in the note.

5. Handover

The written note and the spoken handover fail the same way: the receiver does not know the patient. I-PASS standardized both across nine hospitals and 10,740 admissions, and medical errors fell 23% while preventable adverse events fell 30% — non-preventable events did not change, which is what you would expect if communication was what improved. Handover took no longer (Starmer et al, New England Journal of Medicine 2014). Two caveats: a pediatric population, and a before-and-after study rather than a randomized trial.

I-PASS	What you say	Worked example
Illness severity	One word, so the receiver knows how hard to listen. For anyone unstable, add the code status and who to call.	Stable · “watcher” · unstable. “Unstable — full code, husband’s number is in the chart.”
Patient summary	Age, main problem, why admitted, what has happened since	“72-year-old admitted three days ago with community-acquired pneumonia, improving, off oxygen since this morning.”
Action list	What needs doing tonight, each with a time	“Chase the blood cultures after 20:00. Repeat potassium at 22:00 — it was 3.2 and she has had 40 mmol.”
Situation awareness and contingencies	What might go wrong, and what to do — phrased if X, then Y	“If she spikes a fever, send repeat cultures and a chest x-ray before changing antibiotics. If the potassium is still under 3.5, give another 40 and recheck in the morning.”
Synthesis by receiver	The receiver reads the plan back. This is the only step that confirms anything arrived, and the one most often skipped	“So — stable, chase cultures after 20:00, potassium at 22:00, and hold antibiotics unless she spikes.”

Running the list is the same structure spoken aloud: issue by issue, in order of importance, each with its differential, investigations pending and completed, and management. Day 1 covered the thinking behind it.

The Rounds TableNov 2014 · 28 minDubious Acronyms — Handoff QualityThe I-PASS trial, where standardizing the written handover changed error rates. The second half is unrelated.Listen Now

Reflect

Two questions instead of a quiz. Neither needs ward experience; both can be answered before your first shift.

1. A plan entry as it often gets written: “#3. Hyponatremia. Repeat sodium in the morning.” The sodium was 128 yesterday and is 125 today. Rewrite it so a resident covering overnight, who has never met this patient, would know what you think is going on and what to do if she became confused at 03:00. Three sentences is enough.

Your rewritten plan entry

2. You have not started on the wards yet, so imagine your first night covering one. You are called about a patient you have never met, and all you have is the note written that morning. (a) Without looking back up the page, write down what you would want that note to tell you. (b) Now compare your list with the four things this post says a note has to carry. What did you leave off?

What you would want a note to tell you about a patient you have never met

Please do not include patient identifying details — no names, initials, dates, medical record numbers, or any detail that could identify a specific patient or encounter. Write about your reasoning, not about a real person.

Authors and Review

Dr. Zahra Merali, MB BCh BAO, FRCPC, MHPE
General Internal Medicine Physician, Sunnybrook Health Sciences Centre. Assistant Professor, University of Toronto.

Dr. Valerie Kim, MD
Co-author. Chief Medical Resident, Core Internal Medicine, University of Toronto.

Content developed with the assistance of Claude (Anthropic). Reviewed annually and updated as needed. If you identify an inaccuracy, please contact medicinepods@gmail.com.

Documentation and Handover

Documentation and Handover

Start Here

On the Wards

1. Who Reads It

2. The Progress Note

When you cannot name the cause yet

3. Discharge Summaries

Presenting complaints

Course in hospital

Medications

Follow-up instructions for medical professionals

Follow-up instructions for patients

4. The Legal Minimum

5. Handover

Reflect

Authors and Review

Further Reading

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