One of the most common reasons that I see interns do badly is because they want to memorize the patient and memorize the plan to make the notes later on. I did this as well early on while an Intern myself. I used to write dozens of papers and keep in my pocket.
This did not work for me, and I did not see many other residents that could successfully pull it off.
First, notes should never take a long time to write. There should NEVER be a time where you could use the "I didn't have time" or something along those lines. A brand new note is a 10mins (TOPs) deal, 5mins if its a follow up. The trick is that notes simply puts down whatever you saw in diagnostic imagining/tests and whatever you discussed with the patient's care team. You shouldn't need to take 10mins to describe "Echo today showed depressed EF of 35% and some regional wall abnormalities and as a result cardiology will go ahead with cardiac cath tomorrow to evaluate for ischemic cardiomyopathy. In the meantime continue with ASA and Statin. Will consider starting B blockers when respiratory function improves and BP recovers" that takes 20secs to type down.
How about remembering to present. Well, what I see happening often is that the intern tries to present the chart. Just present the patient. If the patient has been hospitalized for a while, just present the highlights "Patient admitted in Aug of 2017 for acute hemorrhagic stroke secondary to uncontrolled hypertension, she spent multiple weeks in the ICU due to complications and at the wishes of the family, the patient continued to receive aggressive measures. She has been back and forth the ICU for the past 3 years including multiple intra-cranial bleeds, craniectomy, revision, respiratory failure due to pseudomonas pneumonia, pneumothorax due to necrotizing pneumonia, seizures, GI bleed and multiple episodes of septic shock due to complicated UTI associated with chronic foley. Her most recent admission to the ICU is because of cardiac arrest, she is not a candidate for temperature management..." and go to present the pertinent for that day.
Perhaps it is a bit late in the year to be missing stuff, however, you are an intern and this is the time where if you miss something, you have a senior resident and an attending supervising you to point out what you missed. Don't be terrified of missing something because it is normal. Being nervous and afraid just makes things worse as you get performance anxiety. Present in a more relaxed way. Once I outgrew my fear of missing info, I went to rounds with 1 line of info per patient and that line had the BMP/CMP/VItals and fluid in/out information that's all. Everything else was verbal. Half the time I wouldn't even look at my paper, I would say "BMP and CMP are fine except for AKI which is improving compared to yesterday. If attending wanted something I didn't have, we would look it up in the computer at the bedside.
