Hi, Just wondering how one would go about memorising all the things a patient says during a medical history? I am not sure if we're meant to write anything down because isn't that not giving your full attention to the patient? I have heard that some very experienced clinicians don't usually write anything down until they finish everything but is there a way they memorise so much? Am I just finding it difficult to memorise everyhting because I might not have experience with every system of the body? Any help or tips is appreciated. Thanks everyone
It is true that over time, your brain gets better trained to make a good H&P out of what the pt word vomits, and to remember the salient points you need.
As a med student, and to this day, I use white coat clipboard to take notes. I sewed a special pocket to fit it as a med student, as a resident it just fit in the pocket as is.
Anything I write by hand I remember best, even without looking. Less so on the computer.
Here's the thing about clipboard/notepad vs EHR use re: patient feelings.
From standardized patient feedback as well as in practice, I was frequently complimented FOR using a clipboard. Why? Many patients expect you to take notes based on prior experience, and usually they see docs doing this on computer (some docs don't do all of the above, obvs). But they liked the clipboard approach more.
Studies have shown how much patients hate you being on a computer. Many reasons. Clipboard is less of a physical obstacle between you and the patient, easier to maintain intermittent eye contact, and to have your body language oriented in a way that has been scientifically shown to indicate interest in communication. Namely, eye contact, having your body directed towards the patient, and leaning in.
I won't say there is
evidence for the idea that patients seeing you write down what they say, by hand as above, which may be taken as a sign of interest in what they are saying, as superior to you working on a computer screen. However, I have had patients say that taking notes made it seem like I was more intently listening than had I not used it at all. Ie, they preferred the clipboard approach overall. I won't say using a clipboard is superior to not using one per the evidence, I will say that it is clearly superior to using a computer imho. Ipads and the like used as a notetaking not typing device may serve a similar function.
All this is to say, I would highly encourage you to take notes, but to avoid using a computer while a patient is talking to you.
I have more ideas to describe how to do this efficiently.
TLDR:
Basically, I think taking notes is appropriate as you need at any point in training. I think there are better and worse ways to do this as far as how patients perceive this. Some argue this will create a dependence on note taking, that if you don't take notes, you will teach yourself not to need it. What is most important is that you get the job done safely and efficiently no matter your method.
