Before any tool writes a note for you, you need to know what a good one looks like — because you'll be editing, signing, and defending notes for the rest of your career, and you can't edit toward a standard you don't have. Here is the H&P, section by section, judged the way attendings actually judge it.
The one-liner is the whole case
"67-year-old man with CAD s/p stents, diabetes, and CKD presenting with three hours of exertional chest pressure." Twelve seconds, and every reader knows the stakes, the priors, and where this is going. The one-liner is the hardest sentence in medicine to write well because it's a clinical judgment disguised as a summary: you are choosing which of the patient's fifteen attributes matter for this presentation. Students who write strong one-liners are demonstrating synthesis; students who write "67-year-old male with multiple medical problems presenting with pain" are demonstrating that they haven't decided what the case is about yet.
HPI: a story with a spine
The HPI is chronological narrative, not a symptom checklist. Onset, quality, progression, what made it better or worse, what the patient did about it, why now. Two habits mark a strong HPI:
- Pertinent negatives live here, chosen deliberately. "No fever, no vomiting, no urinary symptoms" in an abdominal-pain HPI tells the reader which differentials you were actively excluding. The negatives you choose reveal your reasoning as clearly as the positives.
- The patient's own words for the chief complaint. "Pressure, like someone sitting on me" is data. "Chest pain" is a category.
The exam: write what you did
The fastest way to destroy an attending's trust is a documented exam finding you didn't elicit. A focused, honest exam — with the relevant systems examined thoroughly — beats a template's twelve-system fiction every time. If you didn't do fundoscopy, the note shouldn't say you did. This sounds obvious until the first time a pre-populated template offers you a complete normal exam for one click, which is exactly when it stops being obvious. (This matters double when AI drafting tools enter the picture; a fluent draft will happily document thoroughness that didn't happen, and deleting it is your job.)
Assessment: commit
The assessment is where students hide, and where they're graded. "Chest pain, rule out ACS, rule out PE, rule out dissection" is a list of fears. An assessment commits: "Most likely unstable angina given the exertional pattern and known CAD; PE less likely with no pleuritic features or risk factors, but D-dimer sent given the recent flight; dissection unlikely with equal pressures and no tearing quality." That paragraph shows ranked probability, reasoning for and against, and a plan that follows from the ranking. It's also — not coincidentally — exactly the medical decision-making that billing and medicolegal review care about later in your career. The habit pays forever.
Plan: by problem, with a why
Number the problems. Under each: what you're doing and the one-clause reason. "Heparin drip per ACS protocol — pending serial troponins" beats "heparin" because the note's future readers (the night float, the consultant, you at 3 a.m.) need the why to safely change the plan when conditions change.
Three habits that compound
- Read great notes. Find the attending or senior whose notes make cases instantly clear, and reverse-engineer them.
- Write the assessment before you present. If you can't write it, you don't have it yet.
- Never sign what you haven't read — advice that becomes only more important as more of medicine's first drafts get written by software.
Master the skeleton now. Whatever tools you use later, they'll be drafting toward your standard — and this is it.
tebIQ builds documentation tools for every stage of training, including a free pathway for residents. When you get there: tebiq.com.