How bad is submitting prog notes, d/c summaries late by several days as an intern?

[Caddyologist]

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[operaman]

Bad habit. Fix it now. If that’s the only issue you’re having then it may never become a big deal, but it’s definitely one of the things that can get piled on if you get placed under more scrutiny. I’ve definitely seen this kind of thing get residents (and attendings) put on probation or the equivalent.

Signing a note and back dating the date of service isn’t that big a deal provided you’re very clear about the timing. It does put you at some risk though, especially if there’s ever some kind of adverse event and then the record shows you dropping notes after the fact. On paper it looks like you were neglecting the patient and then tried to cover your tracks. Again, usually not a big deal until it is.

To quote my chief from July 1st of intern year: I don’t care if the notes are good, I only care that the notes are done.

 

[GoSpursGo]

Not acceptable for progress notes. If you need to do them from home at 1130 when you get home then that’s what you do, it’s necessary for billing and frankly for coherent communication among services for the patient. Sorry about life events, but everyone is busy and has a personal life. There is no excuse for this.

D/c summary is less vital unless the patient has follow up shortly after d/c but I would say a week is the absolute latest you should let it go. If it happens frequently though you’re gonna get a talking to from your attendings and PD. If there is an expectation that they are done sooner then figure out how to do that.

Sorry, this is intern year. You can only play the “I’m a new intern” card for so long. Don’t become the intern who is noticeably lagging behind your peers

 

[mvenus929]

Agree with above. Submitting progress notes a day late turns into not completing clinic notes for days to weeks if you don't stop this habit now. And all that certainly affects patient care.

Your progress notes should be done by the end of the day. If you're struggling with this after implementing some of the tips above, then work with your senior/chief to get better on your specific EMR.

DC summaries should be done within 48 hours of discharge, but as GoSpursGo stated, doing them a little later isn't the end of the world--provided they don't bounce back to the ED or present to their PCP in the meantime.

 

[GoSpursGo]

And another point on dc summaries is that some hospitals will allow you to write a combined progress note/dc summary on day of discharge. So if you can do that ON TIME you’ll save yourself a note in the long run

 

[RangerBob]

Agree-very bad habit. Fix it now. We’ve had attendings whose privileges were revoked because because they were in the regular habit of writing/dictating notes late (op notes, dc notes, etc). It lead to multiple patient care issues.

My personal rule is all notes signed before I go home. Don’t be the doc who signs them all at midnight, then gets only a few hours of sleep before starting the whole process over again—those docs are miserable. You either have to learn to be more efficient, or if you’re a perfectionist, to be ok with “good enough.”

Intern year can be tough. But most residency programs have some version of copy forward. If not, they have copy/paste. Progress notes should only take a few minutes to write and you shouldn’t have that many to write as an intern. H&P’s and DC summaries take longer, but you should be able to develop a regular habit/rhythm to write them quickly.

As a resident our notes were long, and had some of our thought process. I don’t know why—none of our attendings asked us to document all our thoughts/differential—that’s what rounds were for. As an attending, my notes are to the point.

Keep in mind if you’re always signing notes in the future, you’re doing the same amount of work you would’ve done if you were always in the present/caught up. You’re only deferring work to the future. It actually makes life harder. Think of Spanish class (or other foreign language)—it’s actually usually easier to get an A than a C because the C students are always playing catch up. The A students do the same amount of work each day, but they never got behind at first so their daily work keeps them ahead.

Be the A student. Always be caught up—especially as an intern/resident. Spend the extra day or two to do the extra work now to catch up, and from then on never sign notes lates unless something big came up. Habits built in residency follow you lifelong, so build good ones now.

 

[RangerBob]

And another point on dc summaries is that some hospitals will allow you to write a combined progress note/dc summary on day of discharge. So if you can do that ON TIME you’ll save yourself a note in the long run

But what would be the purpose? You can only bill for one note, so you may as well just write the dc note and any relevant info that would’ve gone in the progress note for that day would go into the dc summary (if important enough to convey to PCP/others).

My partner and I (PM&R) write our progress note assessment/plans as succinct running discharge summaries. So it only takes us about 2-5 minutes to write a dc summary—it’s basically all copy and paste (and edit!) from last progress note, H&P, final therapy notes. It’s super quick to write and we get multiple PCPs tell us our discharge summaries are more helpful than the majority they come across.

OP—I’m not a hospitalist (or intern) and I know that job can be really busy. My daily workflow is round, write all notes/enter orders, prep admit orders/H&P (they all come to rehab in the afternoon), see new admits, finish H&Ps, then go home. I rarely need to deviate from that system.

I learned as an intern it helps to have all your progress notes pended by rounds. So I came in a bit earlier, got all my notes ready, and after rounding only had to make any adjustments that came up, and then signed them before any admits had arrived. Made the day much more relaxed

 

[GoSpursGo]

But what would be the purpose? You can only bill for one note, so you may as well just write the dc note and any relevant info that would’ve gone in the progress note for that day would go into the dc summary (if important enough to convey to PCP/others).

My partner and I (PM&R) write our progress note assessment/plans as succinct running discharge summaries. So it only takes us about 2-5 minutes to write a dc summary—it’s basically all copy and paste (and edit!) from last progress note, H&P, final therapy notes. It’s super quick to write and we get multiple PCPs tell us our discharge summaries are more helpful than the majority they come across.

So… it seems like we are in agreement about doing a combined progress note/dc summary on day of discharge? I’m not sure where you were disagreeing with me… the only point is that some hospitals have required portions in progress notes and dc summaries that may not perfectly overlap, so you just have to make sure that you do everything that is required for both.

I absolutely detest notes that turn a/p into a running dc summary. Yes, it works from a billing perspective, and it makes your job easier when it comes time to write the dc summary, but it’s garbage from a communication perspective. As a specialist who has both primary patients as well as consults (Heme/onc), it takes me much longer to review those kinds of notes when I’m consulted to have a sense of what problems are actually active. it also becomes very easy to fail to update all of the changes so you wind up getting med lists and problems that are out of date because nobody bothered to change it. Much better is to have a dc summary with running hospital course pended and update each day. Which I understand is tough in the first month of residency, so in July I will give residents a pass, but after that If I’m on and one of my residents keeps a full hospital course in a regular progress note I make them change it to only contain the information that is currently relevant.

OP—I’m not a hospitalist (or intern) and I know that job can be really busy. My daily workflow is round, write all notes/enter orders, prep admit orders/H&P (they all come to rehab in the afternoon), see new admits, finish H&Ps, then go home. I rarely need to deviate from that system.

I learned as an intern it helps to have all your progress notes pended by rounds. So I came in a bit earlier, got all my notes ready, and after rounding only had to make any adjustments that came up, and then signed them before any admits had arrived. Made the day much more relaxed

This part I completely agree with. Coming up with a system for how you approach the day, and prepping your notes early, makes the day go much more smoothly. Of course some days things come up and the you know what hits the fan, but in general having a system will help massively with time management

 

[RangerBob]

So… it seems like we are in agreement about doing a combined progress note/dc summary on day of discharge? I’m not sure where you were disagreeing with me… the only point is that some hospitals have required portions in progress notes and dc summaries that may not perfectly overlap, so you just have to make sure that you do everything that is required for both.

I absolutely detest notes that turn a/p into a running dc summary. Yes, it works from a billing perspective, and it makes your job easier when it comes time to write the dc summary, but it’s garbage from a communication perspective. As a specialist who has both primary patients as well as consults (Heme/onc), it takes me much longer to review those kinds of notes when I’m consulted to have a sense of what problems are actually active. it also becomes very easy to fail to update all of the changes so you wind up getting med lists and problems that are out of date because nobody bothered to change it. Much better is to have a dc summary with running hospital course pended and update each day. Which I understand is tough in the first month of residency, so in July I will give residents a pass, but after that If I’m on and one of my residents keeps a full hospital course in a regular progress note I make them change it to only contain the information that is currently relevant.

This part I completely agree with. Coming up with a system for how you approach the day, and prepping your notes early, makes the day go much more smoothly. Of course some days things come up and the you know what hits the fan, but in general having a system will help massively with time management

Sorry--I phrased things poorly. Regarding progress notes, I guess my question is why it's even needed if you're writing a dc summary that day. So I was confused why there's even talk of a combined note.

I guess we'll have to disagree on the a/p that turns into a dc summary. All I can say is we keep ours succinct and to the point, and multiple providers have gone out of their way to compliment us on ours compared to acute care hospiatlist dc summaries. Consulting docs seem to appreciate it as well as they can usually open our last progress note and see what's been going on, rather than read through every note.

Once again though, we keep them succinct, unlike the notes from the FM residency who have A/P's that go on for pages. There's literally a paragraph for each problem--that is definitely something no consulting doc wants to comb through, and no PCP has time to review that.

My partner and I update our a/p daily to avoid the pitfalls you mention. But it's also easy for us on rehab, as 50% of the time there's no change from day to day. So it's a bit different compared to acute care.

 

[GoSpursGo]

I guess we'll have to disagree on the a/p that turns into a dc summary. All I can say is we keep ours succinct and to the point, and multiple providers have gone out of their way to compliment us on ours compared to acute care hospiatlist dc summaries. Consulting docs seem to appreciate it as well as they can usually open our last progress note and see what's been going on, rather than read through every note.

Once again though, we keep them succinct, unlike the notes from the FM residency who have A/P's that go on for pages. There's literally a paragraph for each problem--that is definitely something no consulting doc wants to comb through, and no PCP has time to review that.

My partner and I update our a/p daily to avoid the pitfalls you mention. But it's also easy for us on rehab, as 50% of the time there's no change from day to day. So it's a bit different compared to acute care.

Yeah I can’t speak to rehab, and I’m sure there is a way to potentially keep a running hospital course in the a/p that is useful. But in practice whenever I’ve seen a resident or APP try it, it winds up making the note awful to pick through as a consultant—much more like the resident nites you described!

 

[RangerBob]

Yeah I can’t speak to rehab, and I’m sure there is a way to potentially keep a running hospital course in the a/p that is useful. But in practice whenever I’ve seen a resident or APP try it, it winds up making the note awful to pick through as a consultant—much more like the resident nites you described!

There's your problem!

I remember trying to read a VA NP's primary care note. It made literally no sense! Everything was copy/pasted (and NOT edited), imaging from the last 5 years was included. It was the longest primary care note I'd ever seen. And the end results were to place a few referrals for relatively simple things.

I've seen the massive note bloat/carry everything forward become more common with some outpt docs lately too. The notes can be really hard to read and understand what's going on. The "edit" part of "copy/paste/edit" is the most important part.

One of my IM collegues worked at a hospital where ALL records were digitized when they moved to the EMR. So 90 year old patients who were born/raised at that hospital system had 90-year old notes. Even APGARs! But the notes back in the 1920-30's far simpler. They were often on a note card, and basically said "edema worse--increase lasix." Multiple PCP visits would be documented on one note card. Obviously that info isn't helpful to consulting docs, but back then you had physician lounges and spoke with your consultants more (whether in person or phone), so I'm willing to guess coordination of care wasn't any worse (and perhaps was better) than today.

End rant on EMRs... I guess it could be worse--we could have all of today's documentation requirements AND have to hand-write it all

 

[Smurfette]

Hello all,

New medicine intern here, very slow at note writing. Sorry I have several Qs:

Some days with patients I have started the progress note (PN) one morning, say at 7am for example and I've not "submitted" it until 24-48 hours later. Or I haven't put in the dc summary for 5 days after the pt discharge when it's supposed to be done sooner. On 1/3 of my patients this has happened so far.
I just try to present well in the morning at rounds, then I'm busy doing tasks after rounds, then I finish some of the notes, come home and end up putting the rest off or falling asleep. I've had some life events happen in the past month or so and I've been sleep deprived/stressed. I know that realistically a PN shouldn't take very long though. I've seen numerous threads on speeding up.

In what ways and how bad is this? What repercussions are there to not submitting a note on time for an intern? Is it something where it would only be bad if a patient had a bad outcome? (because some of these are not complex patients so realistically the senior resident would manage it okay -- I submit the notes on my sickest patients on time/first). Or is just the act of not having a intern note submitted for this long a bad thing?

FYI my EMR shows 1 time for time of service (can be changed) and another time for time the note is submitted (can't be changed)

And also if I am supposed to do daily progress notes on a patient on wards, and for example I start a note at 6am on 7/1 then submit it at 10pm on 7/2, so roughly 40 hours later-- what should I put in the note? should I just write this note to cover all events from 7/1 as if the events on 7/2 hadn't happened yet? This would be writing the note as if I was writing it at the end of the day on 7/1. Then I could write another note asap for 7/2 events (and also submit it that night) to cover those events from 7/2. So in this example, if a note is considered "on time" if it's submitted within 24 hours of the time of service, then the first note would be late but the 2nd one would be on time.

A similar question is if someone wrote a note on 7/1 and forgot to sign it for several days. Would signing it 7/3 for example mean that you're certifying that note covers the patient info up to your date/time of signature? Or can you sign it 7/3 only intending the note to cover events of 7/1? Thanks a lot guys

-delirious intern

OP,
You really need to sign progress notes on inpatients the same day. I'm surprised your senior resident and attending haven't been on you about this....yet. If you are able to get the complex patients' notes done, you really shouldn't be having issues with the less complicated people as those should be quicker. The discharge summaries are less important.
You need to figure out where your difficulty is--are you unfocused? Unclear on the plan? perfectionistic and keep rewriting the notes? Not sure what to write? time management? The sooner you figure out where your difficulty is, the better, because this issue will absolutely be viewed as a problem if it persists. If you are having difficulties finishing notes and completing tasks, you may need to ask for tips on how to get more efficient getting the tasks done to free up time for notes.
It's July and there is an element of "figuring it out" that interns are allowed. But you need to get better/faster throughout the month to avoid finding yourself under some scrutiny.

I will also mention that most hospitals have regulatory requirements and you will get deficiency letters if you aren't completing notes, discharge summaries, and signing off on orders in the requisite time. These vary from anywhere from a week to a month at my hospitals depending on what it is. Eventually the deficiencies can lead to suspension until you finish all the delinquent charts.

 

[mvenus929]

I've seen the massive note bloat/carry everything forward become more common with some outpt docs lately too. The notes can be really hard to read and understand what's going on. The "edit" part of "copy/paste/edit" is the most important part.

Some of my colleague's notes are like that. I'm sitting here scanning through them like 'you don't need the birth history in the note every time they see you... if it's pertinent, write it in the paragraph summarizing the reason for their visit'. It's not needed for billing anymore (except on the initial consult, because some insurance companies still take consult codes).

 

[operaman]

OP,
You really need to sign progress notes on inpatients the same day. I'm surprised your senior resident and attending haven't been on you about this....yet. If you are able to get the complex patients' notes done, you really shouldn't be having issues with the less complicated people as those should be quicker. The discharge summaries are less important.
You need to figure out where your difficulty is--are you unfocused? Unclear on the plan? perfectionistic and keep rewriting the notes? Not sure what to write? time management? The sooner you figure out where your difficulty is, the better, because this issue will absolutely be viewed as a problem if it persists. If you are having difficulties finishing notes and completing tasks, you may need to ask for tips on how to get more efficient getting the tasks done to free up time for notes.
It's July and there is an element of "figuring it out" that interns are allowed. But you need to get better/faster throughout the month to avoid finding yourself under some scrutiny.

I will also mention that most hospitals have regulatory requirements and you will get deficiency letters if you aren't completing notes, discharge summaries, and signing off on orders in the requisite time. These vary from anywhere from a week to a month at my hospitals depending on what it is. Eventually the deficiencies can lead to suspension until you finish all the delinquent charts.

We had a pgy2 who was suspended for delinquent documentation and ultimately had to remediate the whole year. Due to a very forgiving and understanding PD plus that resident being well liked otherwise and who worked hard to fix the issue, they graduated.

But I’ve definitely heard of other programs terminating residents for this kind of thing if it continues and especially when it snowballs.

 

[Crayola227]

We had a pgy2 who was suspended for delinquent documentation and ultimately had to remediate the whole year. Due to a very forgiving and understanding PD plus that resident being well liked otherwise and who worked hard to fix the issue, they graduated.

But I’ve definitely heard of other programs terminating residents for this kind of thing if it continues and especially when it snowballs.

Yes, this kind of thing can END your career at any point from now to attending, OP.

You HAVE to get it together.

Notes may not seem like a big deal, but remember from a certain POV, the hospital which bills them and pays you, it's LITERALLY the most important part of your job. Like, we could actually dither about which is more important, that you don't kill patients or that your notes are on point. Honestly, I would say the hospital leans to the latter. The good physician with poor notes can always be successfully sued. The bad physician with airtight documentation OTOH.... I can tell you which is preferred by your employer. Sure, being both good and good notes is ideal, but if you can only achieve one for now.... focus on the notes.

Don't let anything idealistic about learning or helping patients give you any false feelings of assurance or make you take notes for granted. They don't have to be good from a perspective of reality or being a joy to read. They must be billable and defensible in court. That is the #1 thing to nail down. Don't let anything take away from achieving those two items in your notes.

So they must be timely.

To reiterate, you can get under the radar for this, and you can EASILY be fired for this. In fact, this is literally one of the easiest objective measures you can fail on that will give them something bulletproof to fire you over. That and duty hours, which can be tracked by when you put in orders and when you sign notes.

Keep your nose clean on those fronts. I don't care if you violate duty hours, and I don't care if you lie about them, but remember you can be caught lying about duty hours by when you sign notes and orders. No one cares if you start a note or read EMR on your own time, so signing in/out of EMR on an audit is not how they will necessarily catch you violating hours, or worse, being *caught* lying about them.

My post is where to start on "Not getting terminated by your program 101"

I don't want to freak you out, but I do want you to get this under control (notes on time, appear to make duty hours in EMR) asap.

 

[GoSpursGo]

but if you can only achieve one for now.... focus on the notes.

I agree with a lot of what you wrote, but this is a bit too far IMO. Ultimately, the attending is responsible for the documentation, making sure that it is billable and would hold up in court, and the attending can edit as needed. The most important thing for residents to do is to learn how to manage patients, so if they can not kill anybody then as long as they sign *something* that I can bill for (and edit as necessary) I'm happy enough. Naturally I'd like the notes to get better by the end of intern year (and especially by the end of residency) but it shouldn't be the priority.

 

[Gastrapathy]

I’m confused how this is possible. Is no one co-signing your notes?

 

[Crayola227]

I agree with a lot of what you wrote, but this is a bit too far IMO. Ultimately, the attending is responsible for the documentation, making sure that it is billable and would hold up in court, and the attending can edit as needed. The most important thing for residents to do is to learn how to manage patients, so if they can not kill anybody then as long as they sign *something* that I can bill for (and edit as necessary) I'm happy enough. Naturally I'd like the notes to get better by the end of intern year (and especially by the end of residency) but it shouldn't be the priority.

Totally fair, and good points. I was being a bit over the top just to drive home that on time notes really are a huge deal, because I think that can really get lost on people. It doesn't *feel* like it should be such an important part of the job or doing medicine.

I should have pointed out, and it goes with what you're saying, that in order for the attending to do what you're saying, they need on time notes more than they need quality late notes.

Some perfectionistic interns really need to rewire their brain for what their fears are vs what their job is demanding (killing patients vs on time notes) in order to make it a priority.

So no, don't kill the patients. But reorient yourself to getting the notes done on time.

And yeah, the attending will fix the plan and the note. But they have to have a note, to fix.

 

[Crayola227]

I’m confused how this is possible. Is no one co-signing your notes?

Yeah I don't get it. Wonder if there's a systemic issue?

In a community setting, the attending would track down an intern in the afternoon wondering where the hell the notes were because he wanted to sign them and go home and not think about it again.

Someone somewhere should be noticing what the heck is going on.

Maybe they are just cutting them slack right now because it's still early July or they have bigger problems elsewhere with some othet intern?

If so OP has just gotten lucky and needs to start finishing these notes before they get pulled into a scary meeting.

 

[FutureInternist]

My organisation for the day in intern year (and even now 12 years later) was always 3 basic Qs for each pt

1. What is pt getting that they should not be (why still IV antibx, why still on O2, why on morphine).

2. What is pt not getting that they should (PT, amb O2 sats)

3. Why is pt still in the hospital?

This helped cull down the vast amount of info etc that we are “forced” to put in a note down to the nitty gritty, because while hypoK may be important, the unprovoked PE needing lifelong anticoag that you need to get Case Management or pharmacy’s help to see which one insurance will cover is more important.

I also make a daily list of all pts that are to be DC’d the next day and write their PN for the day as a DC summary

- 67 yo F admitted on 7/1/22 for chest pain, found to have PE, started on X,
Echo showed Y, switched to Z.
Amb O2 sats on 7/5 were 86% & hence she was set up for O2.
Seen by PT who recommended SNF
Rx electronically sent to her pharmacy.
Given unprovoked PE, needs lifelong anticoag
Advised on need for f/u with Hem/Onc
Awaiting rehab placement
Plan for DC in AM if bed can be found.

Then the next day, actual DC takes 35 seconds.

Disagree with folks saying DC summary can be delayed since folks go to rehabs all the time, and even if going home, they could always be readmitted.

For me, I hand each pt their DC summary with “Take to your appointment with your PCP” stamped on it, cos having been on the other end, nothing is as frustrating has having a hospital DC f/u, and finding pt on 2 new meds, with 3 old ones DC’d and pt having no idea why.

If you can get the top 3-4 dx and plans in, that is a good note for an intern & that should be the main focus, while you work on timing, organisation etc

 

[FutureInternist]

Like, we could actually dither about which is more important, that you don't kill patients or that your notes are on point. Honestly, I would say the hospital leans to the latter.

Sad how true this is….

 

[RangerBob]

My organisation for the day in intern year (and even now 12 years later) was always 3 basic Qs for each pt

1. What is pt getting that they should not be (why still IV antibx, why still on O2, why on morphine).

2. What is pt not getting that they should (PT, amb O2 sats)

3. Why is pt still in the hospital?

This helped cull down the vast amount of info etc that we are “forced” to put in a note down to the nitty gritty, because while hypoK may be important, the unprovoked PE needing lifelong anticoag that you need to get Case Management or pharmacy’s help to see which one insurance will cover is more important.

I also make a daily list of all pts that are to be DC’d the next day and write their PN for the day as a DC summary

- 67 yo F admitted on 7/1/22 for chest pain, found to have PE, started on X,
Echo showed Y, switched to Z.
Amb O2 sats on 7/5 were 86% & hence she was set up for O2.
Seen by PT who recommended SNF
Rx electronically sent to her pharmacy.
Given unprovoked PE, needs lifelong anticoag
Advised on need for f/u with Hem/Onc
Awaiting rehab placement
Plan for DC in AM if bed can be found.

Then the next day, actual DC takes 35 seconds.

Disagree with folks saying DC summary can be delayed since folks go to rehabs all the time, and even if going home, they could always be readmitted.

For me, I hand each pt their DC summary with “Take to your appointment with your PCP” stamped on it, cos having been on the other end, nothing is as frustrating has having a hospital DC f/u, and finding pt on 2 new meds, with 3 old ones DC’d and pt having no idea why.

If you can get the top 3-4 dx and plans in, that is a good note for an intern & that should be the main focus, while you work on timing, organisation etc

Thanks for pointing this out. As a rehab physician I am very much in agreement--DC summaries are extremely important and should be done before the patient comes to rehab, so we have a summary of what happened. I would say about 30% of the time patients come to us with a dc summary. Most of the time they don't.

When a patient comes to us with a discharge summary and a correct DC med rec (that's another story), an angel gets its wings

 

[Dral]

Yep, get this fixed. Intern year is learning the art of the line where you get good important information in your notes, but can also write them efficiently.

People do read these notes. As someone who goes into charts fairly often to read others' notes, it is super frustrating to open up a note that was obviously entered but then not completed. (Also don't be the person who mentions all the things about a rash in other parts of the note, but in PE it says 'Skin: Dry supple, without significant rashes or lesions' or the lymphoma patient who has obvious LAD but the note says "No LAD" in PE).

Since others use your documentation, you can understand that you have to give good relevant information, but also have them finished in a timely manner.

You have just started so you probably don't have a good process in your mind of how the PN flows and how to write a more or less 'standardized' version for the common diagnoses/plans you're seeing. My advice is do the best you can, but get your notes done on the day of service/discharge. As the year goes on, you can work in ways to be more descriptive and give better information. At the beginning you probably have to give up a bit on one of those. As I said, I'd give up on details a bit now (within reason) so you can get them done same day.

Look at ways to be efficient. Even ask your fellow residents for tips on efficiency.

For instance, EPIC lets you blow the last few labs into your notes by typing in .lastlab. I use this in the result notes for when I call back patient results. It takes 5 seconds opposed to the 5 minutes or more it would take me to type in CBC/CMP results and whatever else by hand.

 

[rokshana]

your notes are too long. In this day and age, with EMRs, its hard to gauge, but your note really should not be longer than a page (front and back) in written form. I was taught that the A/P should bone the longest part (for a resident, gets smaller as an attending). You have been used to writing these detailed (sometimes annotated) notes as a med student...thats not what you need to do as an intern/resident. Yor note should be shorter than a med student's, but longer than an attending's.

if you have Dragon/MModal, use it. Its talk to text and you can see if you are being concise or are having verbal diarrhea (when you don't know what is going on, you tend to be the latter).

Bullet your HPI with the pertinent information- complete sentences are not needed (and most people don't want to wade through it).
If you must do complete sentence, be brief and concise.

If you are using an EMR such as Epic, make your templates for the common things that you will admit or for the phases you are constantly using , then its just searching for your .phrases. Yes, there is work up from, but ask your seniors for their templates and the modify them to you. If you don't know how to do this...LEARN! Talk to IT and ask them to help you set up your .phrases.

For progress notes, pre chart before rounds (even if you have to come in early to do this) and then just finish up after rounds...aim for your PN to be done by noon conference or at least by 130p...then you just have to deal with D/C summaries and and admission notes in the afternoon.

For admission notes, prep your H&P as you do chart review before seeing the pt...then all you have to do is add what you learn form the pt and details to your A/P.

Learn how to import data such as labs and imaging, and you don't need to import everything! most recent and maybe a prior for comparison if there has been a change...if their A1c has been 10% for the last 10 years...you do not need to include every value!

Remember when using a cut and paste option, PROOFREAD it...nothing worse than saying someone is A&Ox3, NAD when they were intubated the night before...

And don't leave until you have finished your work...you will become more efficient because you want to go home...going home and leaving things undone, just promotes your procrastination.

Its only a few weeks into July...ask for help...because this can become a BIG issue and could very well get you in front of a resident progression committee and remediation...you DON'T want that.

 

[GoSpursGo]

Disagree with folks saying DC summary can be delayed since folks go to rehabs all the time, and even if going home, they could always be readmitted.

For me, I hand each pt their DC summary with “Take to your appointment with your PCP” stamped on it, cos having been on the other end, nothing is as frustrating has having a hospital DC f/u, and finding pt on 2 new meds, with 3 old ones DC’d and pt having no idea why.

Very fair. I guess I just think that if the OP is drowning and he has to fix a timeliness problem on progress notes vs. DC summaries, then the progress notes problem is obviously more pressing. From a pure, practical, "what is going to get me in trouble as an intern," a few late d/c summaries won't get noticed but progress notes definitely will. But FWIW I also try my hardest to co-sign d/c summaries on the date of discharge, and by the middle of intern year I would hope the OP can do the same.

 

[cj_cregg]

I would not let this fly for my junior residents.

For progress notes - General rule of thumb on our service is notes in by noon. Aside from the issues with billing and just general good practice and such as mentioned above, this is a significant patient care/patient safety issue. The whole team, consultants, nursing, etc. needs to be able to look at the chart and know the plan for the day, and they can't do that without a note.

For DC summaries - less of a huge deal, but as someone who sees patients in primary care clinic and SNF it makes it VERY hard for me to provide appropriate follow up care for the patient when I don't have a discharge summary. 48 hours is a good rule of thumb but I'd say ideally for patients dcing home it's ideal to sign your dc summary before you go home on the day of discharge, and for patients going to SNF, IPR, psych, whatever other facility, it's nice to have it done when you sign your dc orders so it can go with the patient to the facility.

Find a couple of your friendly neighborhood senior residents and ask them to (1) go through their workflow for writing progress notes/rounding and (2) review some of your notes to see if there are spots that can be cut or tightened up a bit. Do this with multiple people so you get multiple perspectives. It sounds like you recognize that this is an issue and are ready to be proactive about fixing it, which is the important thing, and asking for help now before somebody else figures out it's an issue will be a much better look than having to get a Talking To later on.

All that said...intern year is tough and I'm sure you are doing your best!! Ask for help early and often, that's what your seniors are there for, and you will be amazed at how quickly you learn and grow. Good luck!!!

 

[greatnt249]

As someone who used to have this problem (though not nearly to the degree of lateness OP was describing), OP, I can assure you that when you sign a progress note next day or even days after the encounter because you think the content needs to be "perfect", your attending is not going to be thinking "well, the note was late but dang this intern deserves a Pulitzer for the pristine content of this note." Most assuredly, they are probably thinking "how in the world did it take this long to get a progress note in the chart," regardless of the note's content. They don't know if you keep forgetting to sign them or if you truly are taking that long to write progress notes. At a certain point, it will snowball on you as you're trying to keep up with the day's events AND trying to remember what the plan on the patient was 2 days before.

And for all you "pre-prep" note writers out there, for the love of all that is holy, please proofread and update the note to reflect the vitals, room number, and time that you actually saw the patient when you sign the note. Nothing is worse than seeing an H&P signed by the resident on an incoming transfer where the time on the note is 4 hours before the patient even got to the hospital or even was in a bed. We all know these copy/paste/forward functions exist; however, the note can't look like you utilized those functions. It's tempting to pre-write an H&P; however, for the new interns/residents, it's important to have your own thought process as to what's going on with the patient. I've seen too many instances where the H&P was verbatim what was received in sign-out or what was already in the chart and when I ask the resident to elaborate further, I get a "I don't know, that's just what I got in sign-out." Anchoring bias is real, and the earlier in your medical career that you can recognize it, the better off you'll be.

 

[hallowmann]

I've seen residents have their contracts non-renewed for this type of thing (notes piling up).

It needs to be fixed. I'm surprised your senior isn't talking to you about it already. Mine would talk to me when I had them into the afternoon or finished them right after shift in intern year. Inpatient notes should really be done same day or at the latest <24 hrs after the encounter. Nothing is more annoying than cross-covering or covering the night float, something happening to a patient (even the rock garden will have a GIB or code stroke or arrhythmia periodically), and having a note not be complete so we have no idea what actually happened. Its one thing to have clinic notes be a few days behind, but inpatient, no way.

Your notes don't need to be great, it really should say the bare minimum, what the patient said and what is different today. That's it. We're talking 2-4 sentences in the HPI and a few bullet points in the plan. Other stuff need only to be added if its pertinent to those two things. Each note should take you <5 min, especially one on a not so acute patient, but as an intern it may take you 15 min.

In our hospital DC summaries had to be done same day and on some services prior to discharge, so I honestly don't know how you're signing it days later. What if the patient is readmitted? The team needs to know what happened, and its not easy scrolling through tons of progress and consult notes.

 

[B1GM0N3Y86]

First, I would not make excuses. This irritates senior residents when an intern is making excuses for incomplete notes.

Second, senior residents or attendings would have had a field day with interns over this. I recall seeing a couple interns as a senior resident have this problem. We all understand occasionally this happens, but not 1/3rd of the encounters. They should be done that day, DC summaries can wait a day or two if needed but they should be done also in timely manner.

From my experience tho, if this continues to be a problem it would be from a lazy intern. I say this since even slow interns will normally speed up if they spend weeks on end typing notes up through late evenings at the hospital. Nothing makes you become quicker than forcing yourself to do all your notes regardless how much there is by end of day. You learn to type faster, make favorites lists, or come up with a system while om wards that helps keep you organized and thus more efficient. I hope you are not the lazy intern and you truly want to become efficient.

Also, this problem you have affects those around you trying to provide good medical care and thus patients can suffer. I say this since many handoffs from the day team to thr night team aren't the best. Either too much or too little is ever relayed from intern to intern. Completed notes can help with this problem. As pages come in to the resident on float they can view the note if needed to get a better understanding

Good luck and ask for help from a senior resident or fellow intern. Continue looking for ways to become more efficient. It's still early, you have that on your side. Acknowledging a problem exists is the first step into fixing it. You are already one step closer today.

 

[dozitgetchahi]

OP,
You really need to sign progress notes on inpatients the same day. I'm surprised your senior resident and attending haven't been on you about this....yet. If you are able to get the complex patients' notes done, you really shouldn't be having issues with the less complicated people as those should be quicker. The discharge summaries are less important.
You need to figure out where your difficulty is--are you unfocused? Unclear on the plan? perfectionistic and keep rewriting the notes? Not sure what to write? time management? The sooner you figure out where your difficulty is, the better, because this issue will absolutely be viewed as a problem if it persists. If you are having difficulties finishing notes and completing tasks, you may need to ask for tips on how to get more efficient getting the tasks done to free up time for notes.
It's July and there is an element of "figuring it out" that interns are allowed. But you need to get better/faster throughout the month to avoid finding yourself under some scrutiny.

I will also mention that most hospitals have regulatory requirements and you will get deficiency letters if you aren't completing notes, discharge summaries, and signing off on orders in the requisite time. These vary from anywhere from a week to a month at my hospitals depending on what it is. Eventually the deficiencies can lead to suspension until you finish all the delinquent charts.

When I was an intern/resident, basically we could not leave until the notes were signed. Attendings expected to be able to addend the notes immediately at the end of the day. I was always told that if the attending couldn’t addend the notes same day, they couldn’t bill for that encounter-and that meant the attendings were going to be on your ass immediately to finish them before everyone went home. That was how each day ended, and you made yourself go faster with the notes to GTFO. D/C summaries were a little bit different, but there was still an expectation that those were done rapidly too. I’m fairly surprised that someone is leaving without having progress notes done the same day? At my program if you signed out patients without having the notes done and something happened with patient care that night such that the night housestaff had no idea what to do, you’d be in for an ass kicking.

OP: as an intern I usually noticed people writing ridiculously complicated, long, overly detailed notes. I clearly remember one note I opened cross covering as a resident where the HPI spanned the entire length of the computer screen, and then kept going as I scrolled down. Cut that **** out, and also learn how to use your EMR to your own advantage. Figure out the templates, dot phrases, etc etc that you need to succeed. Most EMRs have ways of shaving a lot of time off note writing. If all else fails and you have a ****ty EMR, do what some of my co residents did and make a Word document with all of your prefabricated phrases etc and cut and paste out of it. If you have rolling computers, bring them with you into the patient rooms and type while rounding or while you are talking to the patient.

 

[Kaustikos]

When I was an intern/resident, basically we could not leave until the notes were signed. Attendings expected to be able to addend the notes immediately at the end of the day. I was always told that if the attending couldn’t addend the notes same day, they couldn’t bill for that encounter-and that meant the attendings were going to be on your ass immediately to finish them before everyone went home. That was how each day ended, and you made yourself go faster with the notes to GTFO. D/C summaries were a little bit different, but there was still an expectation that those were done rapidly too. I’m fairly surprised that someone is leaving without having progress notes done the same day? At my program if you signed out patients without having the notes done and something happened with patient care that night such that the night housestaff had no idea what to do, you’d be in for an ass kicking.

OP: as an intern I usually noticed people writing ridiculously complicated, long, overly detailed notes. I clearly remember one note I opened cross covering as a resident where the HPI spanned the entire length of the computer screen, and then kept going as I scrolled down. Cut that **** out, and also learn how to use your EMR to your own advantage. Figure out the templates, dot phrases, etc etc that you need to succeed. Most EMRs have ways of shaving a lot of time off note writing. If all else fails and you have a ****ty EMR, do what some of my co residents did and make a Word document with all of your prefabricated phrases etc and cut and paste out of it. If you have rolling computers, bring them with you into the patient rooms and type while rounding or while you are talking to the patient.

I agree. I'd also add that OP should have his notes evaluated by senior/co-residents. Unless English is a new language to you or you are horrible at typing, there's really no reason for you to spend so much time writing notes.
And it's definitely not cool for night team or cross-cover to not have an update on what happened during the day in the chart.
Lastly, get better with time management.
Good luck

 

[Candidate2017]

This is a patient safety issue.

Your hospital team, nurses, and consultants need to know what's going on. Today. Right now. That's the point of a note. Otherwise, you're being a huge jerk to everyone. As echoed above, what kind of hospital/training program are you at where this kind of neglect is tolerated?

It doesn't matter what excuses you make for being very late with your notes. At this point of awareness, it's an intentional shirking of duties. Maybe you need to take a leave or quit medicine if you can't come to terms with getting notes done on time.

 

[rokshana]

This is a patient safety issue.

Your hospital team, nurses, and consultants need to know what's going on. Today. Right now. That's the point of a note. Otherwise, you're being a huge jerk to everyone. As echoed above, what kind of hospital/training program are you at where this kind of neglect is tolerated?

It doesn't matter what excuses you make for being very late with your notes. At this point of awareness, it's an intentional shirking of duties. Maybe you need to take a leave or quit medicine if you can't come to terms with getting notes done on time.

You do realize he has been an intern for a grand total 2 weeks…this frankly is a drop by his seniors…how is it that they have not corrected this issue? How are they not looking at his notes at the end of the day and not seeing one… have not asked him about it?

When I was the senior, in July-sept( basically the time everyone intern was new to the inpt service)I read every single note that the interns wrote to give them feed back so they could craft their note …

And as an attending, I would want to see the note by that evening… and if I didn’t… it’s the senior that I would question… now mind you, in July the 2nd year is just as brand new, but they are the one responsible for their team… i may be more forgiving on July than I would be in say, May.

I get it…and it seems like he gets it to some extent, that this is a problem… but he needs guidance from those ahead of him to teach him what to do… it’s why he is an intern.

 

[Kaustikos]

You do realize he has been an intern for a grand total 2 weeks…this frankly is a drop by his seniors…how is it that they have not corrected this issue? How are they not looking at his notes at the endo of the day and not seeing one… asked him about it?

When I was the senior, in July-sept( basically the time everyone intern was new to the inpt service)I read every single note that the interns wrote to give them feed back so they could craft their note …

And as an attending, I would want to see the note by that evening… and if I didn’t… it’s the senior that I would question… now mind you, in July the 2nd year is just as brand new, but they are the one responsible for their team… i may be more forgiving on July than I would be in say, May.

I get it…and it seems like he gets it to some extent, that this is a problem… but he needs guidance from those ahead of him to teach him what to do… it’s why he is an intern.

You're absolutely right. Which is my problem and why recommended he ask his seniors and co interns for help. I did the same thing as you did: reviewed my intern notes to make sure they were okay. Also made sure they weren't overworked. Had several times where we had 6-7 discharges on same day. I basically took over half. Why? Because I want these patients out!! Lol

But, again, as you stated: your seniors and attendings should be helping.

 

[NotAProgDirector]

Totally agree with the sentiment here.

I'll also add that it's important to get DC summaries and outpatient office notes done the same day if possible. When someone comes back to the ED, or calls after hours for some help -- if the note is missing you will get complaints.

 

[dozitgetchahi]

There's your problem!

I remember trying to read a VA NP's primary care note. It made literally no sense! Everything was copy/pasted (and NOT edited), imaging from the last 5 years was included. It was the longest primary care note I'd ever seen. And the end results were to place a few referrals for relatively simple things

When I was a resident, there was a hospitalist attending that was notorious for doing this kind of stuff - basically he would just cut and paste the subjective and A/P from all the consultants notes and slam it all together in his own notes every day - very little of his notes were actually his own writing. (He was also infamous for calling consults for the stupidest and most ridiculous of things, including having renal come to replete small amounts of potassium etc - so he basically did nothing for his patients himself, and didn’t write anything in the notes that was his own material either.)

 

[Neurocrit]

Ive never heard of anybody doing this. Its such a no no that it must get snuffed out pretty quickly if it is happening.