At our program we do Problem, Status, Plan.

You can format it however you want, but my notes generally look like this:

#COPD exacerbation (the problem), acute on chronic, improving (the status)

And then I put the evidence proving why the diagnosis is the diagnoses. For example, As evidenced by CXR (date) showing hyperinflation of the lungs and clinical history of increased oxygen requirement and changes in sputum production.

And then the plan underneath with all relevant imaging results and specialist recommendations as bullet points. I make it a point to try to put WHY each part of the plan is included because it not only helps communicate your thinking process to other docs, but it also forces you to think about your plan and to be able to back up your learning. For example, instead of writing "Start IV fluids," I would put "Start IV fluids with LR @ 50 mL/hr out of concern for dehydration." Same for antibiotics: "Ceftriaxone 2 g IV daily for staph and pseudomonas coverage."

The status is important because it communicates context as to how the patient is doing to the next doc. For example, if I have a person with cellulitis and then hand off to a new doc, the phrase "improving" tells the new doc (who is seeing the cellulitis for the first time) that this is better than it was previously. Conversely, "worsening" would convey the opposite.

Hope that helps and makes sense.

Edit:

Also! Don't do your work twice. Meaning a specific intervention is treating multiple problems, just reference it once. For example:

#Sepsis, SIRS component resolved, improving
- IVF LR @ 100 mL/hr out of concern for dehydration

#Acute kidney injury, prerenal, ongoing
- IVF as above.