What is a Comprehensive Clinical Note?

📝 What is a Comprehensive Clinical Note?

A Comprehensive Clinical Note is a detailed documentation format designed to capture all relevant aspects of a patient’s medical history, assessment, and ongoing care plan. This format is typically used for more complex consultations, such as first-time visits, multi-system assessments, or when extensive background information and evaluation are needed.

The structure of a comprehensive note ensures that all critical areas are addressed, facilitating thorough communication between healthcare providers and improving continuity of care.

✏️ Structure

Section	Description	Example
Chief Complaint	The primary reason the patient is seeking care, documented in their own words.	"Patient presents with a 3-day history of fever, sore throat, and fatigue."
History of Presenting Illness (HPI)	A detailed account of the patient's current problem, including onset, progression, and severity.	"The symptoms started 3 days ago with a mild sore throat, progressing to fever (up to 39°C). The patient reports no significant relief with over-the-counter analgesics."
Past Medical History (PMH)	A comprehensive review of the patient's prior medical conditions, surgeries, or hospitalisations.	"Hypertension for 10 years, well-controlled with medication. No history of diabetes or asthma."
Past Surgical History (PSH)	Documentation of any previous surgeries, procedures, or hospital admissions.	"Appendectomy in 2010, no complications."
Family History	Relevant medical conditions in immediate or extended family members.	"Father with a history of heart disease, mother with Type 2 diabetes."
Social History	Lifestyle factors such as occupation, substance use, social support, and living situation.	"Non-smoker, occasional alcohol use. Lives with spouse and two children."
Allergies	Known allergies, including medications, food, or environmental triggers.	"Allergic to penicillin, develops rash and swelling."
Current Medications	A list of medications the patient is currently taking, including dosage and frequency.	"Lisinopril 10mg daily for hypertension, Paracetamol 500mg as needed."
Vitals	Physiological measurements such as blood pressure, heart rate, temperature, and respiratory rate.	"BP: 130/85 mmHg, HR: 78 bpm, Temp: 37.8°C, RR: 16 bpm."
Immunizations	Record of the patient's immunisation status, including vaccines administered.	"Up to date on all childhood immunisations, flu vaccine last received in 2023."
Physical Examination (PE)	Detailed findings from the clinician's physical examination of the patient.	"Mild erythema of the throat, no exudates. Clear lungs on auscultation, no lymphadenopathy."
Lab Results	Results from laboratory tests, including blood work, urinalysis, and other diagnostics.	"CBC shows mild leukocytosis, WBC: 11.5 x10^9/L, CRP elevated at 45 mg/L."
Imaging Results	Findings from diagnostic imaging, such as X-rays, MRIs, CT scans, etc.	"Chest X-ray clear, no signs of pneumonia or pleural effusion."
Assessment	The clinician's interpretation of the patient's condition, including a differential diagnosis and clinical reasoning.	"Most likely viral pharyngitis, possibility of bacterial infection not excluded. Differential includes strep throat."
Plan	The next steps in patient care — treatment plan, investigations, referrals, or follow-up.	"Prescribe symptomatic treatment with Ibuprofen for fever, throat lozenges. Rapid strep test to rule out bacterial infection. Follow-up in 3 days if no improvement."
Prescription	Medications or treatments prescribed during the consultation.	"Ibuprofen 400mg every 6 hours as needed for fever."
Appointments	Scheduled future appointments or referrals.	"Follow-up appointment in 3 days for re-evaluation."

🏥 When is it used?

Comprehensive Clinical Notes are essential when a holistic view of the patient’s health is required. It is particularly valuable for:

Initial consultations and new patient visits
Chronic disease management reviews
Specialist or multidisciplinary team assessments
Complex or multi-system presentations
First visits to new healthcare providers or clinics

👥 Who uses it?

General Practitioners (GPs) in general practice settings
Specialists across fields like oncology, cardiology, endocrinology, etc.
Nurse Practitioners performing comprehensive assessments
Allied Health Professionals working in a collaborative care model

🌍 Where is it available?

The Comprehensive Clinical Note format is available across Australia and New Zealand, adaptable to the needs of each clinical setting.

🔄 Specialty-Specific Adaptations

While the core structure remains the same, the Comprehensive Clinical Note format can be tailored for specific specialties. Below are some examples of how it adapts:

Oncology: Emphasis on cancer history, staging, current treatments, and chemotherapy plans. Sections for tumour markers, oncology protocols, and care coordination are typically included.
Psychiatry: Focus on mental health history, mental status examination (MSE), and psychosocial assessment. Details of previous psychiatric treatments, diagnoses, and risk assessments are central.
Cardiology: Emphasis on cardiovascular risk factors, previous heart conditions, test results (e.g. ECG, echocardiograms), and ongoing cardiovascular management plans.
Pediatrics: Focus on developmental milestones, immunisation history, and paediatric-specific screening (e.g. vision, hearing, growth charts). Includes a heavier focus on family history and social factors affecting child health.
Aged Care: Often includes more detailed sections on activities of daily living (ADLs), cognitive function, and end-of-life care preferences.

🔄 Key Differences from Other Note Types

The Comprehensive Clinical Note differs from other formats, such as SOAP, by capturing a full patient history and current condition. While SOAP is commonly used for more focused or routine consultations, the Comprehensive Clinical Note is ideal for situations requiring in-depth assessments and multi-faceted care planning.