do you write progress notes daily?

[Transformers]

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If no one reads med school student progress notes, is it bad of you don't write them in terms of your grade? They take sooo long but aren't too difficult to write, just tedious especially if not much has changed in the management of an inpatient whos been around for quite some time

 

[hurryupnwait]

It's still good form to write them everyday. After all, you want to show that you can function as closely as a resident does. What I do is write a good note on day 1, then I can just take the existing note and make appropriate changes on subsequent days.

 

[VivaLaVida]

Are you sure no one reads them? My friend and I thought no one read ours but then looking back through the patient record one afternoon he found an attending had copied some parts from his. Another attending sought me out to compliment me on a note I wrote. I would never be sure!

 

[e30ftw]

just feel it out based on your rotation/residents/attendings.

on most of my ms3 rotations i was note-bitch but they went in the chart and all the residents/attendings usually did was sign the note or at most add an addendum so it helped the team.

if your note truly is completely worthless just do what you need to learn, get the grades you need, and beyond that not really care.

 

[mvenus929]

It depends on the rotation. During MS3, I generally wrote notes daily, but didn't write clinic notes (except one time during peds clinic, and was actually praised for that in my evals), or OB progress notes (because that department had a strict policy on student notes). But the others, I wrote notes--some were actually graded, some were used directly by the resident/attending, and others were left to float into nothingness. As a fourth year, I still don't write clinic notes, but on inpatient services, my notes are used--either taken over by the resident and signed, or copied and pasted by the fellow/attending into his/her note.

 

[NickNaylor]

Are you sure no one reads them? My friend and I thought no one read ours but then looking back through the patient record one afternoon he found an attending had copied some parts from his. Another attending sought me out to compliment me on a note I wrote. I would never be sure!

I've had multiple residents/attendings copy my notes verbatim. It doesn't happen frequently, but it does happen.

As far as the OP, if nothing else I think writing notes daily is worth it just to get in the habit of doing so. I mean, really, it's not like you're doing much else (most likely), and unless you have a particularly complicated patient a basic SOAP note written from scratch shouldn't take more than 15-20 minutes. Make that 5-10 if you just copy/paste and make quick changes.

 

[africatree]

So here is the thing....
Yes it sucks that your notes don't count for much
And yes you could skip a day and it might not be noticed
However as a student on the wards one of the things that you are supposed to be learning is how to be an intern. As an intern you will be asked to write good notes, with appropriate documentation not on 2 patients but 10. These 10 notes will be expected to be completed and signed by the time you round at 8 or 9 in the morning.

So my suggestion is instead of asking "Can I skip writing notes because no ones paying attention?" I would suggest that you start bugging your attendings, interns and upper levels to read your notes and critique them.

As a third year resident I get very frustrated with medical students who do this. Part of learning to be an intern is doing the job. I am much more likely to spend the time teaching you things for your shelf if you put out the effort and show your interested in medicine by working hard. Trust me you would much rather make the big mistakes now than as an intern when they count.

 

[JediZero]

Only wrote them on surgery, and even then they didn't need to be extensive. If nothing has changed, what did you need to take so long writing about? Please tell me you're not writing a full H&P daily on someone weeks into their hospital stay...

 

[Stellar Clouds]

So here is the thing....
Yes it sucks that your notes don't count for much
And yes you could skip a day and it might not be noticed
However as a student on the wards one of the things that you are supposed to be learning is how to be an intern. As an intern you will be asked to write good notes, with appropriate documentation not on 2 patients but 10. These 10 notes will be expected to be completed and signed by the time you round at 8 or 9 in the morning.

So my suggestion is instead of asking "Can I skip writing notes because no ones paying attention?" I would suggest that you start bugging your attendings, interns and upper levels to read your notes and critique them.

As a third year resident I get very frustrated with medical students who do this. Part of learning to be an intern is doing the job. I am much more likely to spend the time teaching you things for your shelf if you put out the effort and show your interested in medicine by working hard. Trust me you would much rather make the big mistakes now than as an intern when they count.

+1

Take the opportunity to properly learn how to write notes--believe me, you writing 2 or 3 notes a day is not a large burden. Your burden will go up as soon as you become an intern--I've written as many as 40 progress notes in one day! 😱 Plus getting more practice now will lead to less of a freak out when you take CS.

Your attending may or may not be reading your notes, but I guarantee that they would notice if you stopped writing them. Being lazy as a third year does not bode well for your grade...

 

[evilbooyaa]

Only wrote them on surgery, and even then they didn't need to be extensive. If nothing has changed, what did you need to take so long writing about? Please tell me you're not writing a full H&P daily on someone weeks into their hospital stay...

.... everyone who is more than 2 days into MS3 knows the difference between a full H&P and a SOAP note.

 

[ShinyDome19]

If a daily progress note takes you "sooo long" to write on a patient that has very little change in their care for the day, then you definately need to keep practicing, especially if you are using something like EPIC. What I would suggest doing is write your notes and compare the details that you include vs those included by the residents. This is the best way to learn what's important and what's not. In time this will cut down on the amount of time it takes you to write one.. And since they probably don't use your plan get practice in on developing a plan and modifying it every day and compare it to the residents plan. Plus this can create good conversation points with the resident. Once you get to be a sub-I, you are expected to be able to come up with the plan every day and need to do this without any major help.

 

[DrSnips]

+1

Take the opportunity to properly learn how to write notes--believe me, you writing 2 or 3 notes a day is not a large burden. Your burden will go up as soon as you become an intern--I've written as many as 40 progress notes in one day! 😱 Plus getting more practice now will lead to less of a freak out when you take CS.

Your attending may or may not be reading your notes, but I guarantee that they would notice if you stopped writing them. Being lazy as a third year does not bode well for your grade...

40?!?! That is some monumental cross-cover you got going on there.

 

[Stellar Clouds]

40?!?! That is some monumental cross-cover you got going on there.

Lone intern on the weekend on a busy surgical service.

 

[link2swim06]

Copy. Paste.




But seriously, a lot of patients don't change that much day to day. Update a few lines and re-read to make sure it is current. Also I am a super nerd and use templates a lot. That speeds it up.

 

[Brain Bucket]

Copy. Paste.




But seriously, a lot of patients don't change that much day to day. Update a few lines and re-read to make sure it is current. Also I am a super nerd and use templates a lot. That speeds it up.

That's actually a great idea!

 

[KnuxNole]

Writing daily progress notes will be very helpful as a 3rd year. At first, you might be a bit slow, but that's ok! The more you do them, the more efficient you'll become. As others said, there are patients whose course of stay is more stable with a steady plan. Others, require more elaborate plans. By the time you get to intern year, you want a SOAP note to be easy peasy. Especially since your workload will shoot up, and you have to not only get the notes done, but actively manage the patient.

Also, it's perfectly OK to not get the plan right. That's why you are there. To learn clinical medicine.. Don't be afraid of getting yelled at or scolded for suggesting to order an ECHO or to consider checking thyroid function tests, or to consider adding another antibiotic or whatever. If you are wrong, they will explain why, and you'll never forget it.

 

[alpinism]

+1

Take the opportunity to properly learn how to write notes--believe me, you writing 2 or 3 notes a day is not a large burden. Your burden will go up as soon as you become an intern--I've written as many as 40 progress notes in one day! 😱 Plus getting more practice now will lead to less of a freak out when you take CS.

Your attending may or may not be reading your notes, but I guarantee that they would notice if you stopped writing them. Being lazy as a third year does not bode well for your grade...

Well that sounds like a fun day...

 

[mvenus929]

That's actually a great idea!

Be careful using templates, though. Often the PE and a few other things have to be manually updated... I've heard stories of people going to the morgue with a wonderful looking PE (A&Ox3, BP 120/76, HR 80, etc).

 

[NickNaylor]

Also, it's perfectly OK to not get the plan right. That's why you are there. To learn clinical medicine.. Don't be afraid of getting yelled at or scolded for suggesting to order an ECHO or to consider checking thyroid function tests, or to consider adding another antibiotic or whatever. If you are wrong, they will explain why, and you'll never forget it.

Re: "considering" things, I have actually heard of a few attendings who specifically HATE when plans involve "considering" things, especially from more junior members of the team. I'd just come out with guns blazing and make a suggestion - as you said, as long as you can articulate a reason WHY you want to do a certain thing - even if it may be wrong - attendings seem to be more appreciative of outright making suggestions rather than "considering," which some people consider "weak." Pretty ridiculous in my opinion, but hey, something to "consider."

 

[redpanda]

Yes, I write progress notes daily. As one of my attendings went over at the beginning of the month, there are ways to write a very concise progress note (which is what he wanted!) and once you've formulated a good initial plan, it shouldn't be that hard to update your A/P every day.

Also, I've seen multiple portions of my H+Ps copied into consult notes verbatim. So, yes, sometimes your work is used and, at least, subconsciously appreciated.

 

[Charles_Carmichael]

Re: "considering" things, I have actually heard of a few attendings who specifically HATE when plans involve "considering" things, especially from more junior members of the team. I'd just come out with guns blazing and make a suggestion - as you said, as long as you can articulate a reason WHY you want to do a certain thing - even if it may be wrong - attendings seem to be more appreciative of outright making suggestions rather than "considering," which some people consider "weak." Pretty ridiculous in my opinion, but hey, something to "consider."

I've gotten the same thing a couple of times, but it makes sense. I really shouldn't suggest we "consider" something unless I can articulate why. It seems reasonable -- we really shouldn't plan something unless we have a good reason behind it. I've now gotten into the habit of explaining my rationale behind everything I think we should do and attendings have definitely liked that and have been more willing to do something I recommended.

One thing I've found super helpful is discussing my A&P with the senior before rounds. That way, I'm not articulating my plan for the first time when I present to the attending and I'm making sure I cover all my bases (from the senior's input earlier). Plus, double the teaching!

 

[NickNaylor]

One thing I've found super helpful is discussing my A&P with the senior before rounds. That way, I'm not articulating my plan for the first time when I present to the attending and I'm making sure I cover all my bases (from the senior's input earlier). Plus, double the teaching!

Yup, this is absolutely key to success. Come up with the plan as best as you can, pend your note, print it off, then go talk with the intern/resident and see what they think. It also minimizes the all-too-embarassing episodes of you presenting a plan on rounds to which the senior follows up with an "actually..."

 

[Kaustikos]

Re: "considering" things, I have actually heard of a few attendings who specifically HATE when plans involve "considering" things, especially from more junior members of the team. I'd just come out with guns blazing and make a suggestion - as you said, as long as you can articulate a reason WHY you want to do a certain thing - even if it may be wrong - attendings seem to be more appreciative of outright making suggestions rather than "considering," which some people consider "weak." Pretty ridiculous in my opinion, but hey, something to "consider."

I got scolded for that, too. So now I just flat out state "do X" or "do Y". Same with when I got burned for saying "I guess it's this" as an answer. I just give answers now instead of saying I guess.

One thing I've found super helpful is discussing my A&P with the senior before rounds. That way, I'm not articulating my plan for the first time when I present to the attending and I'm making sure I cover all my bases (from the senior's input earlier). Plus, double the teaching!

Yeah,
I do that, too. But the annoying thing is when I say "do this" for "y problem" and my team says "That's not our problem, that's X team's problem". 😡

 

[mdeast]

The only hard notes to write should be the initial H&P and initial progress note. Otherwise, progress notes (especially in Epic) are just a matter of copying your old note, updating the "subjective" section, making sure the labs auto-populate, and then going through your initial problem list/A&P and updating things if you plan on making any changes. It shouldn't take you more than 15 minutes on most patients.

 

[Stellar Clouds]

Well that sounds like a fun day...

Haha single worst day of intern year (so far), but hey, I survived. Fortunately I don't have anymore surgical rotations, so I really won't be put in that situation again.

 

[calvnandhobbs68]

Be careful using templates, though. Often the PE and a few other things have to be manually updated... I've heard stories of people going to the morgue with a wonderful looking PE (A&Ox3, BP 120/76, HR 80, etc).

Yeah be very careful about this, especially with the physical exam or history. You wouldn't believe the kinds of crap you'll find that's been copied and pasted 50 times for a patient that's just straight up wrong. Best to get in the habit of double checking now before you're in a position to get sued about it.

It's hilarious how many people don't actually read notes and just copy paste stuff. I've several times had a speech/PT/OT note go for the history "per Dr. Calvnandhobbs68 patient is a....."

I'll also second the person who said you don't know sometimes who's reading your notes. I've had attendings a couple times sneak read my notes and not say anything to me about it till halfway through the rotation. I've also had a couple residents copy my notes (and expect me to get my notes done so they can work off them) usually after we've gone over the plan after rounds.

 

[qxrt]

It should be emphasized that resident/intern notes are different from med student notes, and surgery notes are different from medicine notes. Interns and residents are busy with many responsibilities, so we often write "work notes" that emphasize practicality and don't go into flowery prose about why we're considering this or that for the diagnosis/management. When you're a med student, you have much fewer patients and responsibilities but are expected to write notes in more detail so that the residents and attendings can see your thought process -- your job is to learn, not yet to manage.

Surgery notes are also much more brief and less detailed than medicine notes in general; it's the job of the internist to get all the tiny relevant details and review of system that other specialties would gloss over.

 

[D elegans]

I write notes hourly to demonstrate my commitment to patient care

 

[thepoopologist]

If no one reads med school student progress notes, is it bad of you don't write them in terms of your grade? They take sooo long but aren't too difficult to write, just tedious especially if not much has changed in the management of an inpatient whos been around for quite some time

You need to make sure you write good progress notes for your own sake. They may not be noticed anytime this year but if they suck as an auditioning fourth year or as an intern you're in deep ****.

 

[badasshairday]

I read med student progress notes on epic. Sometimes they are the only notes that can give me any history for an exotic CTA including the chest abd and pelvic.

 

[jerseytrash]

You write them because you have to. They're part of the medicolegal documentation and they're used for billing purposes. Also it helps consultants out as the primary team and it helps maintain continuity of care.

Also, it is good form to write a decent progress note (doesn't have to be an absurdly detailed one of course) as long as you put the pertinent details. As a med student I would write more detailed ones with a long subjective section ("Pt c/o bad taste in the bowel prep overnight, was feeling down about his cat running away, etc") but as an IM intern you quickly learn what is and is not relevant so that it usually boils down to something like "No acute events overnight. Pt denies any new complaints, continued 10/10 chest pain, no events on tele".

As before surgical notes (or any subspecialty service whether surgical or medical) tend to be more brief than the primary team notes b/c they're more focused in nature

 

[Stellar Clouds]

You write them because you have to. They're part of the medicolegal documentation and they're used for billing purposes. Also it helps consultants out as the primary team and it helps maintain continuity of care.

Also, it is good form to write a decent progress note (doesn't have to be an absurdly detailed one of course) as long as you put the pertinent details. As a med student I would write more detailed ones with a long subjective section ("Pt c/o bad taste in the bowel prep overnight, was feeling down about his cat running away, etc") but as an IM intern you quickly learn what is and is not relevant so that it usually boils down to something like "No acute events overnight. Pt denies any new complaints, continued 10/10 chest pain, no events on tele".

As before surgical notes (or any subspecialty service whether surgical or medical) tend to be more brief than the primary team notes b/c they're more focused in nature

The only part of a medical student note that can be used for billing purposes is ROS, FM, PMH, and social hx--anything else is considered Medicare fraud (from the AAMC).

 

[KnuxNole]

The only part of a medical student note that can be used for billing purposes is ROS, FM, PMH, and social hx--anything else is considered Medicare fraud (from the AAMC).

Does it still work if the resident writes an addendum to the student note? That is what I did the month I was on service with student notes....of course every patient gets a note written in the chart by an attending who is writing their own added note to mine.

Also, is this EPIC thing that common? Where students can write a note on the computer, and copy/paste things with ease? In med school and in residency, every single progress note I've written is done by hand. Clinic notes are typed, but hospital notes are all written, which makes it hard to read handwritings of certain docs :/

 

[Stellar Clouds]

Also, is this EPIC thing that common? Where students can write a note on the computer, and copy/paste things with ease? In med school and in residency, every single progress note I've written is done by hand. Clinic notes are typed, but hospital notes are all written, which makes it hard to read handwritings of certain docs :/

😱 you're kidding, right? You've hand written every single inpatient note!?!

But yes, the copy paste thing is very common and easy to do. I see it all the time when a consultant directly copies and pastes my HPI.

 

[KnuxNole]

😱 you're kidding, right? You've hand written every single inpatient note!?!

But yes, the copy paste thing is very common and easy to do. I see it all the time when a consultant directly copies and pastes my HPI.

Yes 😳

H+Ps and discharges I dictate, so I just write "H+P dictated" and it gets printed out. Having to write the entire H+P or discharge summaries for everyone might make my hands fall off

 

[mvenus929]

Also, is this EPIC thing that common? Where students can write a note on the computer, and copy/paste things with ease? In med school and in residency, every single progress note I've written is done by hand. Clinic notes are typed, but hospital notes are all written, which makes it hard to read handwritings of certain docs :/

My school has multiple sites for med students to rotate at. Of the five hospital systems we rotate through:
- One is VA and thus has the VA charting system.
- Two have used EPIC all through our clinical years
- One switched to EPIC after I rotated there, but still used some sort of EMR (however horrible it was), so most notes weren't handwritten
- No idea about the fifth one, but I'm fairly certain they have an EMR that is not EPIC.

So yeah, EPIC is pretty common. Most places, at least academic centers, can't get away with having paper charts anymore.

 

[JediZero]

My school has multiple sites for med students to rotate at. Of the five hospital systems we rotate through:
- One is VA and thus has the VA charting system.
- Two have used EPIC all through our clinical years
- One switched to EPIC after I rotated there, but still used some sort of EMR (however horrible it was), so most notes weren't handwritten
- No idea about the fifth one, but I'm fairly certain they have an EMR that is not EPIC.

So yeah, EPIC is pretty common. Most places, at least academic centers, can't get away with having paper charts anymore.

There was some pre-ACA legal requirement that all hospitals move toward EMR. I'm surprised to see how many places still have handwritten stuff, but ten years from now they will likely be entirely a thing of the past.

I like Epic, but Cerner and a few other systems are also pretty big right now...

 

[NickNaylor]

There was some pre-ACA legal requirement that all hospitals move toward EMR. I'm surprised to see how many places still have handwritten stuff, but ten years from now they will likely be entirely a thing of the past.

I like Epic, but Cerner and a few other systems are also pretty big right now...

I've used Cerner and Meditech so far. Cerner was actually ok, but Meditech (what I'm currently using) is totally garbage. Epic is still my favorite.

 

[evilbooyaa]

The hospital I did 3rd year rotations at used hand-written charts on every single patient. We had Sunrise for vitals/orders/any dictations (including H&Ps, D/C summaries, consult notes, etc.) but every patient had at least a barebones H&P and barebones consult note in the chart, with most people going "H&P dictated" with the reference number as an addendum.

As medical students we couldn't dictate or do computer notes. Progress notes every morning( or 2 hours if on L&D) were hand-written in each of the following cases: Medicine, Pediatrics, Psychiatry, Surgery, OB/GYN (incl. Gyn surg as well as L&D).

The only times I did any electronic note writing was on OB Triage and Family Medicine clinic.

On Surgery the residents did an addendum, then the attending wrote a short note themselves.
On Medicine the residents still had to write their own notes (couldn't just be an addendum).
Psych - the attending addended our notes and signed off
Pediatrics - Attending pretty much wrote their own note from scratch
OB/Gyn - For 2 hour monitor checks, residents just signed off. Anytime the lady was checked for dilation, residents wrote the note. Some attendings followed their patients like hawks, others just were paged when the patient moved into serious labor time.
Family Med - Residents looked over student notes (we didn't finalize them) made any changes to A/P as required, then electronically signed it. Student/resident presented to the attending (who took super short relevant notes), who dictated about a 10s A/P per patient at the end of the day.

 

[tco]

On my sub-I, it took me 40 minutes total to write "spectacular" notes on my five patients. You can take 10 minutes per day to learn to write a proper note. Believe me, it will benefit you later.