History Taking

[tcon91]

Hi everyone, we recently had a practice sp encounter to prepare us for a graded encounter coming up soon. At the end of the encounter our sp give us feedback on how we performed. According to the sp after my practice encounter I take "too many notes".

Not sure if the sp is just being nit picky or if I really need to buckle down on this. Basically, I ask one or two questions going like Onset/palliative, provocative and jot down what they say and go through the whole OPQRST. I don't know how else I would do it. I need to take down notes because there's no way I'm going to remember every single little fact for the soap note we have to write afterwards. The sp says she didn't feel like I was engaged with her because of this. I don't know, I thought I did decent job for the first time doing this.

Any suggestions or tips?

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[jrlob91]

What year are you? This will come with time. I am towards the end of my third year and by now I have almost everything memorized, and you'll be surprised how far you will come. For now, take notes. You won't need as many later.

 

[tcon91]

What year are you? This will come with time. I am towards the end of my third year and by now I have almost everything memorized, and you'll be surprised how far you will come. For now, take notes. You won't need as many later.

I'm a first year. Yeah I figured that too. I'm just concerned about the graded encounter coming up.

 

[starri]

Practice, practice, practice.

Over time, you get better at holding it in your head.

 

[68PGunner]

Hi everyone, we recently had a practice sp encounter to prepare us for a graded encounter coming up soon. At the end of the encounter our sp give us feedback on how we performed. According to the sp after my practice encounter I take "too many notes".

Not sure if the sp is just being nit picky or if I really need to buckle down on this. Basically, I ask one or two questions going like Onset/palliative, provocative and jot down what they say and go through the whole OPQRST. I don't know how else I would do it. I need to take down notes because there's no way I'm going to remember every single little fact for the soap note we have to write afterwards. The sp says she didn't feel like I was engaged with her because of this. I don't know, I thought I did decent job for the first time doing this.

Any suggestions or tips?

I never care much about the humanism portion. Always get 95+ on the real thing w my soap note being close to perfect on every shot.

Finally, I suggest for you to condense your soap note and develop a routine for normal pts. That way, you will only need to remember weird stuff down the road. For each pt, I only need to remember 5-10 outliers from my normal routine.

Practice a lot with your classmates. It will become so natural down the road that you can walk into a SP encounter with zero preparation and still ace the thing. This will help you down the road since you have better things to do w your time in your second year like studying for board/test.

 

[hallowmann]

I agree with what others have said.

In addition, note taking isn't a problem per se, but having long pauses in the interaction while you are jotting stuff down or always looking down at your paper when you speak/not making eye contact with the patient because of note taking is a bit of a problem. For this, I would really just practice maintaining eye contact or condensing what you write to shorthand or single words that will remind what they said.

I wouldn't worry too much about it though, like everyone said, its something that improves with time.

 

[tcon91]

I agree with what others have said.

In addition, note taking isn't a problem per se, but having long pauses in the interaction while you are jotting stuff down or always looking down at your paper when you speak/not making eye contact with the patient because of note taking is a bit of a problem. For this, I would really just practice maintaining eye contact or condensing what you write to shorthand or single words that will remind what they said.

I wouldn't worry too much about it though, like everyone said, its something that improves with time.

Yeah this is what she was getting at. Thanks for the short hand recommendation! I'll give that a try next time.

 

[Mr Roboto]

Also if you're able to make small talk with the patient while you're jotting down short things they say.

Like:
you- "What is your diet like?"
SP - "Oh not very good, a lot of fast food, but I've been trying for more fruits and vegetables."
you while writing something short - "I totally understand! It can be hard to keep things balanced when you're busy!"

This way you're "connecting" with the SP while still jotting enough to jog your memory later.

As others have said, keep things brief. Don't write an essay. Don't leave long pauses that feel awkward to the patient. Make eye contact between every question, and try to look the patient in the eye for most of the time when they're answering you.

You'll get better with practice

 

[FrkyBgStok]

I agree with the above. Write short things to jog your memory and trust yourself. In the example above, just write "fast fiod" and use it to jog your memory. Your next one, try to be mindful about how much you actually look at your notes when you type. I bet it is less than you think it is.

 

[mw18]

It's also helpful with SPs to ask if it's okay if you take notes and reassure them of the confidentiality of the notes "If it's okay with you I'm going to take notes so I can make sure I tell my preceptor the whole story, but only she and I will see them."

As others have said, write in shorthand an then periodically do summary statements to make sure you have it right and can interpret your own shorthand.

 

[samac]

You have to develop a system that works for you. Before I walk into the room I take 30 seconds to write "CC OPQRSTa M A PM PS F S ROS" down my paper. This keeps me flowing and if I need to write a little more for something in particular I start the next question. Also work on making eye contact while writing. Looking up a few times makes all the difference" and develop your own short hand.
Example:
I write CC down verbatim but then it's just like this
O- 3 wks
P - no
Q - dull
R - arm
S - 6
T - worse morning
a - cough
M - this one sucks. Write the meds and the dosage.
A - NKDA, no seasonal/animals
PM - HTN, diabetes
PS - tonsils 10 yrs ago
F - M - HTN D - diabetes 2 no sib
S - teacher, smoke 3/day no drink or drug

 

[BluegrassBuckeye]

What is OPQRST that keeps being referenced? We learn OLDCARTS at my school. Is that not the standard at most schools?

 

[mw18]

What is OPQRST that keeps being referenced? We learn OLDCARTS at my school. Is that not the standard at most schools?

onset
palliative/provocating
quality
region/radiatio
severity
timing

 

[GUH]

onset
palliative/provocating
quality
region/radiatio
severity
timing

Also Previous episodes for P

 

[tcon91]

Thanks everyone! Very useful tips here!

 

[acapnial]

Hi everyone, we recently had a practice sp encounter to prepare us for a graded encounter coming up soon. At the end of the encounter our sp give us feedback on how we performed. According to the sp after my practice encounter I take "too many notes".

Not sure if the sp is just being nit picky or if I really need to buckle down on this. Basically, I ask one or two questions going like Onset/palliative, provocative and jot down what they say and go through the whole OPQRST. I don't know how else I would do it. I need to take down notes because there's no way I'm going to remember every single little fact for the soap note we have to write afterwards. The sp says she didn't feel like I was engaged with her because of this. I don't know, I thought I did decent job for the first time doing this.

Any suggestions or tips?

One time I had an SP write in my evaluation that she was annoyed that I didn't take notes. Said it made her think I wasn't taking the case seriously and that it made me appear arrogant. My classmates that didn't take notes said that she wrote almost the exact same thing to them. Sometimes complaints are legitimate complaints and sometimes they're neuroses.