Some help?

Are you using paper charts or an electronic health record (EHR)? Do you work with a problem list?

DancingFajitas said:

Ok, so as a new intern I find myself having some trouble with some things, mainly trying to organize information with respect to assessments and plans. I have trouble with complex patients especially, and a lot of times I find myself at a loss as to what to even put down in the assessment and plan. I try to make a general problem list from the subjective and objective parts of the interaction and if there are any labs or imaging I will pull those in as well and try to come up with a differential; essentially if a pt c/o SOB, has a murmur on exam, and elevated triglycerides, I will put something like: Problem 1-SOB--diff dx COPD, asthma, pneumonia, etc
Problem 2--systolic murmur
Problem 3--elevated triglycerides
Then I will try to say ok to differentiate between the diff dx I will order: x, y, z. Then I will say ok to fix the SOB I will give O2, nebs, whatever. I think its easier for me to do this when I'm on the floor b/c I have time to think about it, but I guess my questions are 1) does anyone have a better format for collecting, compiling, organizing and presenting the info? and 2) does anyone else have this problem when in clinic/outpt settings? 3) how can I improve on this and do it in a faster way?

Click to expand...

Assessment and Plan
List the current Diagnoses from highest to lowest priority. Murmur is not a diagnosis. Elevated Triglycerides would probably be lowest on you're list of Asessment/Diagnosis/Plan
Please do not be vague like that in problem number one. You should be problem specific. There is nothing more frustrating than the E.D. calling me with a Dyspneic patient, and not realizing what is really going on.
You should break up every problem.
Next is listing co morbidities impacting care (including the other conditions the patient may have) and preferably their status (compliant/controlled, Non-compliant/Uncontrolled)
Plan
Admission status (inpatient or observation?)
Radiographic testing ordered with results if available (preferably you're own assessment, coupled with official read if possible -- does patient correlate with Radiographic data available?)
Lab tests ordered
Other tests (EKG, etc)
Consults
Medications
DNR status
Medications

hope this helps.............

Totally agree with andwhat.

First of all, get it in your head that these patients may be complex, but they are not hard. In fact, the more complicated patients you see, the easier it gets... ok? First of all... so don't shy away just because they're complicated. In fact, jump right in there and strive to make an impact in that patient's life.

Now, the note you presented is expected from a medical student, but now that you're an intern you really should be striving towards "making the diagnosis". And it's ok if you can't nail it down right when you're writing your note, but it's helpful to have at least an "impression" (i.e. working diagnosis).

You have lots of work to do, but on one night at home, spend a good portion of the night reviewing your physical exam book because in it, you will need to review how to get a better history and better physical exam skills to practice on when you hit the floors again.

Your example of SOB & murmur is a great example because they can be related or not related and so more information in the history and a more descriptive evaluation of the physical exam will lead you closer to the true diagnosis. (3/6 midsystolic, L mid clavic line, radiates axilla, louder on supine).

Otherwise, why bother, right? Murmur-echo, SOB-PFT, CXR... I mean, you can't do that for every patient. So, first is to review your history & physical exam skills so you can start moving towards "making the diagnosis".

2nd advice is if you don't know the answer, it's ok to list problems in your assessment, the way you have it but one trick is to use the word "suspicious" or "consistent". Like, "2. Murmur - possible new, consistent with mitral regurge, suspicious of left side heart failure". And so now, you're pushing towards a diagnosis. AND, more importantly, it not only justifies your orders (ex: echo, CXR), but in your brain, you've made a decision that certain tests are not necessary (ex: PFT). AND, even better, is when your test results come back and they confirm you clinical impression, that diagnosis is that much more powerful & convincing. And if it doesn't correlate, go back and revisit the patient, and rethink your diagnosis. Maybe the test results don't capture the true picture, which may necessitate another test.

But, if you list problems, order tests based on word association, you're going to run into the problem of having someone who has never seen the patient (i.e. radiologist) making the diagnosis for you.

So... when you call andwhat to admit the patient, you can say, "Hi Dr. andwhat, I've got this 67 y/o who I think has decompensating left side heart failure... blah blah... I'm going to get an echo, start him on lasix... blah blah. Do you mind seeing him in the morning?"

We've all been there. Keep working. Keep trying to advance your skills. That's what residency is for. Hope it helps & good luck.