HiddenTruth said:
ok, so u all talk about writing a good note to make it easier for residents and thus, another step in the right direction for a good eval.
I just started IM--my first rotation-- so can someone elaborate on what's a GOOD note. I understand that it should be concise and thorough, but beyond that??
Also, what do you guys usually include in your physical exam findings on an avg person who maybe oly has an abnormal CVS (CHF exacerbation with rhales on exam only)? How can you be through, and what general thigns do you all include? Like, what do you guys write, for say the rest of the exam which is normal--what are some of the general thigns to write? Sorry for the fragmented thoughts. Appreciate the comments.
The best notes that a student (or anyone, for that matter) can write are:
--Approrpriately thorough yet concise
--Easily readable (good handwriting goes a long way...)
--Include an accurate, up to date "summary" statement (the assessment part of your note)--OR, if you're going to write the A/P together instead of A then P, includes an assessment of each problem, followed by the plan. Each format works better for different kinds of patients. Either way the assessment piece of the note is important.
--Has a clearly understandable plan.
--Acknowledges the imput received from subspecialty teams
(i.e. 1. ID
😛t continues to have spiking fevers at night with negative blood cultures and negative oncologic w/u to date. ID consulted--appreciate imput. Will send labs x, y, and z per their recommendations and await results.) Or something like that. You get the picture.
--Includes trends (for lab values, weights, etc), instead of just that day's values, if appropriate. If you've been following your pt's weight because they're volume overloaded in CHF and up 10 kg from their last hospitalization, the daily I/O and the past few day's weights are invaluable information to have in a note (and on rounds!). Likewise with labs. Any lab that you're actively following on a daily basis and that you're adjusting meds for (electrolytes for example) deserves a mention of at least the past few values. Isolated lab values, without context, don't tell you much in these patients.
--Includes "dispo" as the last problem on the A/P. Every pt needs a plan to get them out of the hospital!
There is a certain language used in writing notes that you'll pick up on as you move through various 3rd year rotations. I'd encourage you to look through your patient's charts (or other patients on your team) and note how others write their notes. Read residents' and attendings' notes to get a feel for the language they use to describe their patients.
Certainly some patients' notes require in-depth thought and analysis and thus writing, but others don't, and you'll get a feel for that too.
For example, if you're following a CF patient who's in the hospital for a clean out with IV antibiotics, you note on day #2 of hospitalization might say something like this:
24 y/o male w/CF, pancreatic insufficiency w/chronic malabsorbtion and IDDM, admitted with recent increase in productive cough and drop in PFTs, here for IV antibiotic therapy, currently day #2/14, doing well.
1. FEN: H/o pancreatic insufficiency as manifestation of CF. No current symptoms of malabsorbtion. Continue pancreatic enzymes 6-7 tabs with meals and 3-4 tabs with snacks.
2. Pulm: H/o CF diagnosed at 3 years of age with multiple hospitalizations for IV antibiotics. Last PFTs show declining pulmonary function. Continue pulmozyme nebs, chest PT, and antibiotics. Check PFTs next week per pulmonary recs.
3. ID: X bacteria grown from sputum and sensitive to current antibiotic regimen of X, Y, and Z. Currently day #2/14 of IV antibiotics. Follow appropriate peak and trough levels and adjust doses as indicated.
4. Endo: H/o IDDM secondary to CF. Current insulin regimen includes Lantus 20 units qhs and regular insulin SS with meals. Continue checking BS qam, qhs, and with meals.
5. Dispo: Pending clinical improvement. Anticipate discharge after 14 day course of abx.
By day #10 of this pt's hospitalization, your note is probably going to look more like this:
24 y/o male w/CF admitted for IV abx, doing well w/improving PFTs and resolving cough.
1. FEN: pancreatic insuff, cont. pancreatic enzymes
2. Pulm: no new cough, PFTs improved from admit, cont pulmozyme, chest PT
3. ID: day #10/14 of abx, all levels appropriate, cont for 14 day course
4. Endo: BS 100s-120s, continue current insulin regimen
5. Dispo: anticipate d/c after compleing day #14/14 of abx.
You get what I mean.
Having said all that, I still think it's more important for med students to learn how to do good patient presentations that to write stellar notes, and the note is best used as a good way to sort through your thinking on a patient and thus help you give better presentations. A good goal for your first rotation on Internal Medicine should be to learn how to present each of your patients in 4 ways (times are approx):
--the initial 10-15 minute admit h&p
--the 5 minute daily presentation on rounds, starting with a 10-15 second patient summary statement
--the 1-2 minute patient summary for calling consults
If you can do this well, I don't care what kind of notes you write!
😀
The best med student presenters are also usually the best listeners--because they've spent a lot of time learning from those around them by listening to how they present. And they can adapt their presentation quickly depending on who they're presenting to--because like it or not, different attendings like things done in different ways. Good listeners pick up on this quickly and adapt appropriately.
Anyways, good luck to you!
