H&P time goal

This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.
chronicidal

chronicidal

Scrub
10+ Year Member
Joined
May 14, 2010
Messages
1,189
Reaction score
359
Just started M3. I want to make concrete and specific goals to improve my efficiency with doing an H&P and write-up while maintaining a reasonable level of comprehensiveness. 1) how long should I aim to complete a H&P+write-up with assessment+plan in? 2) How do I do this. Don't just tell me "practice." What can I practice doing within the next week?
Members don't see this ad.
 
chronicidal said:
Just started M3. I want to make concrete and specific goals to improve my efficiency with doing an H&P and write-up while maintaining a reasonable level of comprehensiveness. 1) how long should I aim to complete a H&P+write-up with assessment+plan in? 2) How do I do this. Don't just tell me "practice." What can I practice doing within the next week?
Click to expand...
What rotation are you starting off M3 with?
 
Members don't see this ad :)
A good MS3 H&P should take half an hour. Yes, you will be pushed to do things faster, especially on surgery, but resist cutting corners. Your H&P is your bread and butter. You have to be good at it. It takes me about 6-7 minutes to do a focused surgical H&P as a PGY3. And when I'm at one of our academic hospitals, one of the best places to get a solid start at figuring out a patient is the MS3 notes because it is chalk full of info that isn't in most resident H&Ps.

Tips:
1) Make a system and stick to it.
2) Ask your initial questions in the same order every time.
3) Pre-write or print an H&P template
4) Don't be afraid to redirect patients when they go off on their tangents. They won't hate you for it.
5) ALWAYS sit when doing an interview. ALWAYS, even if there is no where else to sit but at the foot of their bed.
6) After you step out of a room, tell the patient's story back to yourself as if you were presenting it to an attending, think about what you missed and what you might get asked about. Then double back and get that information. It will be painful, but you will find that the number of double backs will greatly decrease as time goes on.
 
One cannot do a good H&P in under 10 minutes unless it's a very targeted problem (which vascular surgery is). I'm not doubting that mimelim's H&Ps are that quick, but don't feel bad if you're taking longer for an inpatient medicine H&P. Medicine relies on the story to figure out what to do next, while surgery is less so.
 
chronicidal said:
Medicine
Click to expand...
Wonderful. That's a great rotation to start off with for many reasons - one of which is the highly academic nature of IM allows you enough time to write a comprehensive H&P (as well as the IM shelf being good prep for the Surgery shelf). First. I would get this book: http://www.amazon.com/Internal-Medi...=sr_1_3?s=books&ie=UTF8&qid=1403562711&sr=1-3

You can look inside to see exactly why it's an awesome book to use while you're obtaining your History so you don't forget anything and you understand why you're asking certain questions. I agree with above 30 minutes to max of 45 minutes to do a H&P is enough time to be comprehensive yet efficient. I will leave it at that, for now, since that is all you asked.
 
Having an h&p template helps a lot. It can cue you if you forget a question/section and it gives you an organized way to record notes so that you can present off of it if you don't have time to write up your note before rounding.
 
I started with medicine first as well. I think that ideally you should be able to finish it from interview to write up in 45 mins (obviously complicated patients might take longer). I had my own EPIC template I made and used (the defaults are usually too sparse for a med student, at least the ones we had access to). Once the HPI is done the rest shouldn't take that long. I also ended up starting the note while I was in the room, although I know that can be frowned upon since you're not engaging the patient or whatever while you're focused on the note.
 
tco said:
One cannot do a good H&P in under 10 minutes unless it's a very targeted problem (which vascular surgery is). I'm not doubting that mimelim's H&Ps are that quick, but don't feel bad if you're taking longer for an inpatient medicine H&P. Medicine relies on the story to figure out what to do next, while surgery is less so.
Click to expand...

OP do not feel bad in any way shape or form if it takes a while to get taking good H&Ps. Any monkey can operate. Being able to collect information, sort out the important stuff, and develop a plan takes time, practice and ultimately is what will make you a good doctor regardless of what you go into. Surgical residency is of course about learning how to physically operate, but much much MUCH more than that, it is about learning when to operate, who to operate on and probably most importantly who NOT to operate on. A lot of that comes down to good interview skills and ultimately taking a good H&P. Not every school is going to get you the hands on experience that others will, but it will be a crying shame if you graduate as an MD and not be able to take a good H&P!
 
Wordead said:
I started with medicine first as well. I think that ideally you should be able to finish it from interview to write up in 45 mins (obviously complicated patients might take longer). I had my own EPIC template I made and used (the defaults are usually too sparse for a med student, at least the ones we had access to). Once the HPI is done the rest shouldn't take that long. I also ended up starting the note while I was in the room, although I know that can be frowned upon since you're not engaging the patient or whatever while you're focused on the note.
Click to expand...
give_it_to_me_stephen_colbert.gif


Sent from my SM-N9005 using Tapatalk
 
I would say for a starting MS3, an hour max for a H+P sounds reasonable. After that, you'll learn about how to do one, what pertinent questions to ask, and go from there. Same with physical exam stuff, which I find students tend to use a lot of time on that(I remember one student would say they spend 30 mins just on the physical exam!). Quality > Quantity. Dont focus on speed when first starting out.
 
Members don't see this ad :)
KnuxNole said:
I would say for a starting MS3, an hour max for a H+P sounds reasonable. After that, you'll learn about how to do one, what pertinent questions to ask, and go from there. Same with physical exam stuff, which I find students tend to use a lot of time on that(I remember one student would say they spend 30 mins just on the physical exam!). Quality > Quantity. Dont focus on speed when first starting out.
Click to expand...
Except your intern and resident are evaluating you.
 
mimelim said:
4) Don't be afraid to redirect patients when they go off on their tangents. They won't hate you for it.
5) ALWAYS sit when doing an interview. ALWAYS, even if there is no where else to sit but at the foot of their bed.
6) After you step out of a room, tell the patient's story back to yourself as if you were presenting it to an attending, think about what you missed and what you might get asked about. Then double back and get that information. It will be painful, but you will find that the number of double backs will greatly decrease as time goes on.
Click to expand...
Wanted to respond to this part specifically. Every patient I worked with really appreciated it when residents would sit down while taking their H&P after being admitted. It makes a huge difference in how their day/night goes.
 
DermViser said:
Except your intern and resident are evaluating you.
Click to expand...

True, but they would be a douche to ding that person forever on their first rotation + first H+P. Maybe the douchenozzle resident did a stellar H+P in 20 minutes on his first rotation, but very, very few med students will be able to do that on Day 1. Added to the fact that some residents assume all med students are genuises who know everything. As we know, everyone has to start somewhere. Personally, I would never make someone feel bad on their very first H+P. If they take too long, I will give constructive criticism on what to do better to help with time management in the future, and praise them on the good stuff(since you can't only focus on all negative stuff, encouragement makes people feel more confident!).
 
chronicidal said:
Just started M3. I want to make concrete and specific goals to improve my efficiency with doing an H&P and write-up while maintaining a reasonable level of comprehensiveness. 1) how long should I aim to complete a H&P+write-up with assessment+plan in? 2) How do I do this. Don't just tell me "practice." What can I practice doing within the next week?
Click to expand...
This will be the only time in your life that you have practically unlimited time to develop these skills.

While there is a point of diminishing returns, there is no need to rush through when learning a new skill. One of the most important time management skills you can develop is the ability to keep patients on track and to "politely interrupt" when they go into mind-numbing detail about their bunions.

There's lots of good advice above - develop the basics and then build on them. Having a system you follow every time will help keep you organized. You'll learn how to focus those skills based on patient presentation, disease process, specialty, time allotted and attending.
 
HopefulReapp said:
Wanted to respond to this part specifically. Every patient I worked with really appreciated it when residents would sit down while taking their H&P after being admitted. It makes a huge difference in how their night goes.
Click to expand...
I sit down when I talk to patients in the office - it makes it seem like you're spending more time with them than you really are. It also fosters a sense of intimacy, collegiality IMHO.
 
The more H&P you do the quicker you will become. You will take longer at first and that is ok. You are learning. no one walked in the first time and did an H&P in 30 mins (well a good one anyway). Medicine H&P are so long. Come up with a template (cc, HPI, ROS, PMHx, PSHx, Allergies, Meds, FHx, SHx, PE, Labs, Imaging, A/P). Keep a notebook or files on your tablet and list specific questions that need to be asked for the chief complaints you get. For instance chest pain, shortness of breath, weakness, etc. keep a list and reviewing will help with the speed. when you hear chest pain you will automatically know which questions you need to ask. you will miss some information. again this is ok. you are learning. you are not expected to know everything you should ask from day 1. some residents will be douches about it and make you feel bad or look bad in front of attendings. if you can, find a different resident to follow. if not, simply say, I am sorry i missed that but will make a note so i do not miss it again. medicine is the best rotation to practice H&P. do as many admissions as you can.
 
forgot to mention, never present an H&P to an attending that you did not take because if they ask about something and you do not know the answer it will not look good for you. Also do your own physical exam and be sure you have seen the patient. don't be lazy and just print off the h&p and present it like you saw the patient and then don't even know where the patient's room is located. This happened when I was doing my med sub-i and the 3rd year tried this. the attending basically did not acknowledge his presence the rest of the month.
 
I stopped scribing in the Emergency Department before I moved up to where I'm starting med school. I'll echo what was said above: templates, sitting down and being polite are very important. Using shorthand can save you a lot of time writing your patient notes. Reading through sample notes helped me get up to speed so I could stay up with the physicians (we saw 6 patients/hour/physician at times). It's important to read back through your notes. I accidentally clicked +dyspareunia on a patient with a CC of SOB. I'm glad I caught and corrected that before the physician signed the note, lol.
 
Spend 5-10 min looking up their history and fill in as much as you can except for the HPI and ROS.

Confirming the information, especially technical stuff like PSHx and Meds is easier than relying on their blanket recall.

Also make note of relevant imaging for the CC. Last echo report or prior EKG print and bring for comparison if digitally archived.

This trims actual time in the room with the patient down significantly.
 
Winged Scapula said:
I sit down when I talk to patients in the office - it makes it seem like you're spending more time with them than you really are. It also fosters a sense of intimacy, collegiality IMHO.
Click to expand...

So you like to deceive your patients into trusting you. This is a tactic that I must try.
 
drcrispmd said:
forgot to mention, never present an H&P to an attending that you did not take because if they ask about something and you do not know the answer it will not look good for you. Also do your own physical exam and be sure you have seen the patient. don't be lazy and just print off the h&p and present it like you saw the patient and then don't even know where the patient's room is located. This happened when I was doing my med sub-i and the 3rd year tried this. the attending basically did not acknowledge his presence the rest of the month.
Click to expand...

What I do for patients that are admitted overnight is look at the H&P beforehand, get everything straight in my head, think of questions I'd like to ask that the interviewer missed, then go into the patients room and summarize what I know. I'll then ask them if they thought of anything else, or if what I said was correct. Finally, I'll ask them the questions that I thought of while reading the H&P. I'll finish the session with my own physical exam. When I leave the room, I think of my own plan and check it against what they did overnight. If I forgot anything or they forgot anything, I make note of it. This takes, at most, 20 minutes on even the most complicated patient.

That's what I did before I had the year-long vacation that was fourth year, anyway. We'll see what I do in a couple of weeks.
 
I would focus more on quality than efficiency, especially at first and especially on medicine. I googled various sample H&Ps and found some that I liked and worked toward emulating those. I got more efficient as the year went on, but quality was always my focus. I actually ended up with eval comments about the exceptional quality of my documentation on multiple rotations and not one word about being too slow. Remember, students are there to learn, so unless there's a big time crunch and your team is slammed, good residents should expect you to take a little longer as you learn how to do one well.

As for presenting what you don't write, I was asked to do this a lot and just made sure to disclose exactly what I did or didn't do. I would summarize the HPI, recount pertinent exam findings and add anything new/different I found, add any new labs/imaging that had resulted, and present my own A/P.
 
This kid presented an admission H&P on a patient the next morning that he was suppose to round on and acted like it was his. When the attending said let's go see the patient, he did not know where the patient's room was and had not been in the room at all.
 
drcrispmd said:
This kid presented an admission H&P on a patient the next morning that he was suppose to round on and acted like it was his. When the attending said let's go see the patient, he did not know where the patient's room was and had not been in the room at all.
Click to expand...

Ouch. He chose..... poorly.
 
drcrispmd said:
This kid presented an admission H&P on a patient the next morning that he was suppose to round on and acted like it was his. When the attending said let's go see the patient, he did not know where the patient's room was and had not been in the room at all.
Click to expand...
What happened then?
 
The attending gave him a hard time the rest of the month. He was head of the dept. The kid was needing an IM letter from the dept head. He asked me if I thought he would get a good LOR from him. I think he matched this year. He was at a different school than mine.
 
You must log in or register to reply here.

Similar threads

E
  • Locked
H
Replies
2
Views
679
PathNeuroIMorFM
PathNeuroIMorFM
Shunsui
  • Poll Poll
Step 2 dedicated time?
Replies
6
Views
2K
Lifeblood_20
Lifeblood_20
G
Mismatch between goals in PS and CV
Replies
3
Views
530
Giga_chad98683
G
Sram.jpg
Changing From P/F to Letter Grades
Replies
7
Views
1K
14_karat
14_karat
O
P/F on Transcript - Chances for Neurosurgery
Replies
2
Views
1K
omega8
O
Top