Summative Documentation

When documenting multiple times during an extended encounter, each “progress” record should emphasize what has changed since the prior note. Progress notes are about what has changed; they are not meant to be understood in isolation from the rest of the chart.

Interpretive, rather than replicative, notes keep the chart lean, making it easier for other users to appreciate trends and important developments. Reciprocally, clinical decision-making is hampered when important details are buried in unnecessary duplication.

Where documentation by exception is appropriate, summarize lack of change with indicators like “no adverse change” or “within normal limits”.