Section 6.2: Key Components of Medical Records and Progress Notes

6.2.1 The “Why”: From Patient Chart to Evidence Locker

In your pharmacy practice, you are accustomed to viewing a patient’s medication profile. This profile, housed within your dispensing system, is a clean, curated, and highly structured dataset. It is designed for one primary purpose: to provide the necessary information for safe and accurate dispensing. It contains the medication name, sig, prescriber, allergies, and perhaps some basic insurance information. It is, in essence, the “CliffsNotes” version of a patient’s pharmacotherapy history.

The Electronic Medical Record (EMR), also known as the Electronic Health Record (EHR), is the unabridged, multi-volume epic novel. It is a sprawling, complex, and often chaotic repository of a patient’s entire medical life. It contains not just the “what” (the medication list) but the “why” (the clinical reasoning), the “how” (the physical exam findings), and the “what’s next” (the treatment plan). For the prior authorization specialist, the EMR is the single source of truth. It is the evidence locker where every piece of data needed to build a successful case is stored.

The challenge, therefore, is not a lack of information, but an overwhelming abundance of it. A patient with a complex chronic disease may have thousands of pages of progress notes, hundreds of lab results, and dozens of imaging reports. Attempting to read this record from start to finish is not just impractical; it is impossible. Success in this field hinges on the ability to navigate this vast sea of data with the precision of a surgeon. You must learn the fundamental structure of the EMR and the universal language of clinical documentation—the SOAP note—to filter the signal from the noise. This section is designed to give you that skill. We will transform you from a casual reader of a patient chart into a master navigator of the evidence locker, capable of finding the exact data point you need, quickly and efficiently, to win your case.

6.2.2 The Digital Shelving System: Navigating the Core EMR Tabs

Before diving into individual progress notes, you must first understand the fundamental layout of the library itself. While every EMR system (like Epic, Cerner, eClinicalWorks) has a unique interface, they are all built around a common set of core tabs or sections. Mastering the purpose of these tabs is the first step to efficient navigation. This is your library map.

Masterclass Table: EMR Tabs and Their PA Evidence Value

EMR Tab (“Library Section”)	Primary Function	PA Investigative Value (Deep Dive)
Face Sheet / Demographics	A one-page summary of the patient’s core information.	Absolute Verification: This is your primary source to confirm Name, DOB, and Insurance details from the prescription. Any discrepancy must be resolved here. At-a-Glance Info: Often lists the Primary Care Provider (PCP) and key specialists, giving you an immediate sense of the care team. Contact Information: Provides reliable patient and emergency contact information.
Problem List	A cumulative list of the patient’s significant, ongoing medical problems.	The PA Goldmine: This is often the single most high-yield tab. It provides a quick, coded history of the patient’s major diagnoses. ICD-10 Code Hunting: It’s the fastest way to find the correct, specific ICD-10 code for a condition, which is essential for mapping to the payer policy. Comorbidity Assessment: You can quickly assess for comorbidities that might represent contraindications to preferred therapies (e.g., seeing “Chronic Kidney Disease, Stage 4” on the list is a major clue). Onset Dates: A well-maintained problem list includes the date of onset for each diagnosis, helping you establish the chronicity of the condition.
Medication List (“Med List”)	A record of the patient’s prescribed medications, both active and inactive.	Step-Therapy Proof: The “Inactive” or “Discontinued” section is your primary tool for proving failure of preferred alternatives. Look for the stop date and, ideally, a reason for discontinuation. Dose Titration History: You can often see a history of dose changes, which can be used to prove that a patient failed a lower dose before escalating to a higher one. Identifying Duplication/Conflicts: Provides a clear view of the patient’s entire regimen to spot potential safety issues or therapeutic duplications that a payer might question.
Allergy List	A list of all documented allergies and adverse reactions.	Proving Contraindications: This is the primary location to find documented allergies to preferred formulary agents, which is often a valid reason to bypass step-therapy. Allergy vs. Intolerance: You must learn to differentiate. A true IgE-mediated allergy (hives, anaphylaxis) is a hard contraindication. An “intolerance” (nausea, headache) is weaker evidence and requires you to find supporting documentation in the progress notes describing the severity. Payers scrutinize this heavily.
Progress Notes	The chronological narrative of all patient encounters.	The Core Narrative: This is where the clinical story is told. It’s the source for 90% of the justification you will need. We will spend the bulk of this section dissecting these notes. The “Why” Behind the “What”: The Med List tells you a drug was stopped; the progress note tells you *why* it was stopped. This is where you find the clinical reasoning.
Lab Results	A repository of all laboratory data, often in sortable/graphable format.	Objective Data: This is the source for the hard numbers payers require (e.g., HbA1c, LVEF, eGFR, quantitative viral loads, genetic markers). Trending Over Time: The ability to graph results is powerful. You can use it to demonstrate disease progression despite current therapy or, for re-authorizations, to show a positive response to the requested drug. Date Stamping: Lab results have a hard, verifiable date, which is crucial for policies that require data from “within the last 90 days.”
Imaging / Radiology	A collection of reports from imaging studies like X-rays, CTs, MRIs, and ultrasounds.	Do Not Read the Image: Your job is not to be a radiologist. Go to the “Impression”: Scroll immediately to the bottom of the report to the “Impression” or “Conclusion” section. This is the radiologist’s official summary and diagnosis, and it’s the only part that matters for PA. Objective Proof: This section provides objective evidence of diagnoses (e.g., “evidence of tumor progression,” “acute DVT,” “fracture”).
Consults	A repository for notes from specialist providers.	High-Value Targets: These notes are often the most important and data-rich. A single consult note from a cardiologist or oncologist is worth more than five routine primary care notes for a specialty drug PA. Start Here: For any specialty drug, the consults tab should be one of the first places you look. It will contain the most sophisticated clinical reasoning and justification.

6.2.3 The Dewey Decimal System: A Masterclass on the SOAP Note

Now that you understand the main sections of the library, it’s time to learn how to read the scrolls themselves. The vast majority of clinical encounters documented in the EMR follow a universal structure known as the SOAP note. This format is the lingua franca of healthcare, providing a consistent framework for providers to document their interactions and thought processes. For the PA pharmacist, mastering the SOAP note is the key to unlocking evidence with maximum efficiency. It’s the organizational system that tells you exactly where to look for every conceivable piece of clinical data.

Deep Dive: Mining Each SOAP Section for PA Gold

SSubjective: The Patient’s Narrative

Do not underestimate the Subjective section. While payers prefer objective data, the patient’s own story is what establishes the real-world impact of their disease and the failure of other treatments. This is where you find the “color” for your clinical case.

• History of Present Illness (HPI): This is a goldmine for statements that prove medical necessity. Look for phrases like:
  • “Patient reports continued pain rated 8/10 despite taking maximum doses of ibuprofen.” (Establishes severity and failure of OTC therapy).
  • “Patient states the metformin caused intolerable diarrhea and they had to stop taking it.” (Direct evidence of intolerance for step-therapy bypass).
  • “The topical steroid provides minimal relief, and the rash now covers approximately 20% of their body surface area.” (Quantifies severity for a psoriasis drug PA).
• Review of Systems (ROS): Often a series of checkboxes, but can contain clues about side effects from other medications that may contraindicate their use.

OObjective: The Irrefutable Data

This is the section that payers value most. It contains the hard, unbiased evidence that supports the subjective complaints and justifies the diagnosis. Your job is to find the specific numbers and findings that match the payer’s policy criteria.

• Physical Exam: This is where the provider validates the patient’s complaints.
  • Rheumatology: Look for a specific joint count: “Physical exam reveals 8 tender and 6 swollen joints.” This is a hard data point for a DAS28 score.
  • Dermatology: Look for Body Surface Area (BSA) percentage or a PGA (Physician’s Global Assessment) score: “Plaques noted on bilateral elbows and knees, estimated BSA 15%. PGA score is 4 (moderate-severe).”
• Labs & Imaging: The provider will often summarize key results directly in the note. “Recent labs reviewed, notable for an HbA1c of 9.2%.” or “MRI of the lumbar spine confirms severe spinal stenosis at L4-L5.” These statements connect the raw data to the specific patient encounter.

AAssessment: The Diagnosis and Rationale

This is arguably the most critical section of the entire note. It is the provider’s conclusion, where they synthesize all the evidence from the S and the O into a definitive diagnosis and clinical judgment. This is where you find the “money statements.”

• The Diagnosis: Each numbered point in the assessment corresponds to a diagnosis and should have an ICD-10 code. This confirms the diagnosis for this specific encounter. “1. Severe, persistent asthma (J45.50)”
• The Rationale Statement: The best clinical notes include a sentence or two of rationale that is pure gold for your PA submission. Look for statements that summarize the clinical situation and justify a change in therapy.
  • “Despite adherence to maximum dose Symbicort, the patient’s asthma remains uncontrolled with frequent use of their rescue inhaler. A biologic agent is now indicated.”
  • “The patient’s clinical ASCVD and persistently elevated LDL-C > 70 mg/dL on maximally tolerated statin therapy makes them a candidate for a PCSK9 inhibitor.”

PPlan: The Action and The Order

The Plan translates the Assessment into actionable orders. This is where you find the explicit documentation of the medication being requested and the final, definitive proof of previous treatment failures.

• The New Prescription: The plan will explicitly state the order for the new drug. “- Initiate Skyrizi 150mg SQ at week 0, week 4, and every 12 weeks thereafter. E-scribed to CVS Pharmacy.” This confirms the provider’s intent.
• Discontinuation Orders: This is irrefutable proof of step-therapy failure. “- Discontinue methotrexate due to lack of efficacy.” When you find this sentence, you have met a major PA criterion.
• Orders for Labs/Tests: The plan may include orders for follow-up labs. This can help you anticipate what evidence will be available for a future re-authorization review.

6.2.4 Reading Between the Lines: Advanced Note Analysis

Understanding the SOAP format is the foundation, but becoming a true expert requires learning to navigate the complexities and idiosyncrasies of modern EMR documentation. Not all notes are created equal, and learning to quickly identify high-value information while discarding noise is a critical skill.

Specialist vs. Primary Care Notes: A Question of Weight

As mentioned before, notes from specialists carry significantly more weight with payers for specialty drugs. It is crucial to understand why.

• Data Density: A primary care note may be long and narrative, focusing on multiple patient problems. A specialist note is typically shorter, more focused, and packed with the objective data points relevant to their field (e.g., a cardiologist’s note will always have the latest LVEF; a rheumatologist’s note will have the joint count).
• Credibility: Payers view specialists as the ultimate authority on complex diseases. A statement like “biologic therapy is now indicated” from a board-certified rheumatologist is considered a highly credible clinical judgment. The same statement from a PCP carries less weight.
• Workflow Implication: For any specialty drug PA, your first investigative priority is to locate the most recent specialist consult note. Start there. It will almost always contain the most potent and efficient evidence for your case.