Which section of the hard copy medical record contains encounter notes?

• A. Section 3
• B. Section 1
• C. Section 2
• D. Section 4

Answer: (C)

Encounter notes are the narrative documentation of each patient encounter—the subjective information from the patient, the clinician’s objective findings, and the assessment and plan. In a hard copy medical record, these clinical narratives are kept together in the section designated for encounter documentation so the full story of a visit is easy to find and review across visits. That is why the section containing encounter notes is the clinical notes section. Other sections typically hold administrative data, test results, or forms, which do not serve as the primary narrative of a patient encounter.