How to remember what the patient said when you take their HPI and PMH.

[urbanclassic]

I tend to have a hard time remembering what exactly people say to me. I usually remember the gist of it, but little details that may actually be important are hard for me to remember. And of course when nervous that makes it even worse. Anyway, I've been taught that you're not supposed to write a lot down when taking HPI and PMH because it makes you seem impersonal. Does anyone know tips for remembering things patients tell you for HPI or PMH w/o writing a lot or at all? TIA

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[CuttingCorneas]

I've been taught that you're not supposed to write a lot down when taking HPI and PMH because it makes you seem impersonal.

False. Better to have all the details you need than not enough. If you're concerned about seeming impersonal, look at the patient when they're answering questions, nod, use encouraging physical cues, etc. Take breaks to write things down, then bring your focus back to them. You're bound to miss something if you try to remember everything off the top of your head.

 

[calvnandhobbs68]

I tend to have a hard time remembering what exactly people say to me. I usually remember the gist of it, but little details that may actually be important are hard for me to remember. And of course when nervous that makes it even worse. Anyway, I've been taught that you're not supposed to write a lot down when taking HPI and PMH because it makes you seem impersonal. Does anyone know tips for remembering things patients tell you for HPI or PMH w/o writing a lot or at all? TIA

When I'm a patient, I'm definitely happier when the doctor is actually writing down what I say instead of trying to memorize it. You actually run the risk of looking like you don't care enough if you don't write HPI/PMH down because while you're trying to memorize what the patient is saying he or she is still talking to you. Also, how are you supposed to pay attention to the physical exam if you're going over what the patient said the whole time in your head and trying to commit it to memory?

In short, err on the side of writing too much rather than too little.

 

[Siggy]

I tend to have a hard time remembering what exactly people say to me. I usually remember the gist of it, but little details that may actually be important are hard for me to remember. And of course when nervous that makes it even worse. Anyway, I've been taught that you're not supposed to write a lot down when taking HPI and PMH because it makes you seem impersonal. Does anyone know tips for remembering things patients tell you for HPI or PMH w/o writing a lot or at all? TIA

Yea... and I've also been taught that it's better to ask about the patient's kids or job when they're in 10/10 pain or have potential emergent conditions because it builds "rapport." Strangely enough, that only seems to happen with the standardized patients and not the real patients. Write things down as needed. Also the hospital I'm at has 5 page admission H&P packages (including a page for the resident and for the attending) and I'll take 20 seconds to check off boxes before starting my physical.

 

[SpecterGT260]

writing down as you go also gives a good opportunity for the patient to elaborate on things. You take a 2 sec pause to jot something down, half the time the patient will interject something else that may be useful. If it isnt useful, just redirect to something else you want to know.

 

[mmmcdowe]

Organization is crucial. The better you are at maintaining a systematic approach to the H&P, the easier it is to remember it.

 

[mimelim]

Organization is crucial. The better you are at maintaining a systematic approach to the H&P, the easier it is to remember it.

I think this is the most important. Also, you should summarize the high points of an interview with the patient before you leave the room. I usually sum up what the patient has told me into 15-30 seconds worth of info and ask the patient if that is an accurate account of why they are seeing me. Even though 99% of the time I am 100% sure it is accurate, actually reviewing the info helps me commit it to short term memory.

Things tend to get better with time. Obviously the more familiar you are with jargon and just medicine in general the faster you will be and the easier it will be to remember things. I can't remember the last time I wrote something down in an interview.

 

[Charles_Carmichael]

I think this is the most important. Also, you should summarize the high points of an interview with the patient before you leave the room. I usually sum up what the patient has told me into 15-30 seconds worth of info and ask the patient if that is an accurate account of why they are seeing me. Even though 99% of the time I am 100% sure it is accurate, actually reviewing the info helps me commit it to short term memory.

Things tend to get better with time. Obviously the more familiar you are with jargon and just medicine in general the faster you will be and the easier it will be to remember things. I can't remember the last time I wrote something down in an interview.

+1

I usually say something like "Let me tell you what I've got so far and if I got something wrong or you want to add something more, let me know" and then, summarize what I have after I finish the HPI. Works really well, lets the patient know that I've been paying attention to what they've been saying, and also ensures we're both on the same page.

I've never really heard the thing about "you're not supposed to write down a lot." I usually look at the patient when I ask the question and go back and forth between them and my notes while they're answering, so they know I'm paying attention and am just writing down what they're saying. No one's ever complained about it yet.

 

[mimelim]

I don't think anyone will say it is "wrong". I just don't think that people naturally get better and more efficient. A lot of docs like to do focused physical exams while talking to their patients, sometimes you get a better exam if they are focused on telling you their story and not you prodding on their abdomen. You also don't always have a writing surface handy, or even space to sit down (personally I find writing while standing awkward). Another point is that most offices these days will have patients write down their PMH on a form before showing up or when they show up. I went to an orthopedic surgeon (as a patient) a couple weeks ago and filled out a 3 page H&P on myself that they required before you could be seen.

 

[Owlie]

When I went to a doctor and had a chest x-ray because I was having dyspnea, he just sat there for a long time and thought. He finally said, "I just don't know. You have dyspnea." I thought, "I already know that! Hence why I can't breathe in fully...." Haha. He didn't ask much, nor wrote anything down. *Shrug*

 

[SpecterGT260]

When I went to a doctor and had a chest x-ray because I was having dyspnea, he just sat there for a long time and thought. He finally said, "I just don't know. You have dyspnea." I thought, "I already know that! Hence why I can't breathe in fully...." Haha. He didn't ask much, nor wrote anything down. *Shrug*

you..... you can't diagnose "dyspnea" from a CXR.... That is a symptom, not really a finding. 😕

 

[QuaerensIntelle]

It is interesting how much better you will get at this over time...I'm not sure why. That being said, I usually still jot down some notes. I like to do pertinent positives/negatives just in bullet format and then pmh, sx, meds, allergies, social etc in short hand. You don't have to write much to be able to remember everything. The stuff that is hardest to remember is the most boring/factual like when exactly the onset of symptoms was and details about their past medical history. Lastly, if it didn't strike you as important enough to remember it...chances are your attending doesn't want to hear about it either. Brief but complete = golden.

 

[Owlie]

you..... you can't diagnose "dyspnea" from a CXR.... That is a symptom, not really a finding. 😕

Exactly. He said my lungs on the x-ray were fine. He just told me I had dyspnea, which is what I came in for, and had told him. Symptom =/= diagnosis. I don't understand asthma greatly, but my dyspnea occurs without your typical 'asthma' attack in conunction, and during my allergy (pollen/cottonwood) season. My bronchi were not constricted. Oh well :\

 

[SpecterGT260]

Exactly. He said my lungs on the x-ray were fine. He just told me I had dyspnea, which is what I came in for, and had told him. Symptom =/= diagnosis. I don't understand asthma greatly, but my dyspnea occurs without your typical 'asthma' attack in conunction, and during my allergy (pollen/cottonwood) season. My bronchi were not constricted. Oh well :\

I'm sure he was aware that the symptom doesnt equal the diagnosis. Your story made it sound as if the physician used it as a diagnosis......

 

[Owlie]

I'm sure he was aware that the symptom doesnt equal the diagnosis. Your story made it sound as if the physician used it as a diagnosis......

Okay, yes, I realize he wasn't a fool. I don't want to make him sound that way, but it was an odd situation at the time. He didn't ask any other questions, schedule a follow up, refer me. Maybe I'm wrong and it was fine, but I figured there was more that could've been done. But I digress from the OP...


Writing stuff down has to help. There are just too many things to memorize about what they're saying. Plus, reference to that material later, and upon complication could be beneficial.

 

[Wordead]

Exactly. He said my lungs on the x-ray were fine. He just told me I had dyspnea, which is what I came in for, and had told him. Symptom =/= diagnosis. I don't understand asthma greatly, but my dyspnea occurs without your typical 'asthma' attack in conunction, and during my allergy (pollen/cottonwood) season. My bronchi were not constricted. Oh well :\

Can someone with more knowledge comment on this? No workup because a lot of cases are idiopathic, and if it wasn't severely limiting him and there's nothing in the history to indicate lung disease there's no point putting him through a battery of tests? That's what I thought at first glance.

 

[SpecterGT260]

Can someone with more knowledge comment on this? No workup because a lot of cases are idiopathic, and if it wasn't severely limiting him and there's nothing in the history to indicate lung disease there's no point putting him through a battery of tests? That's what I thought at first glance.

That's what I was thinking. Depends on the severity and what the patient thinks dyspnea actually is. Are we talking getting winded after running a mile when you think it should take 2? Is it just congestion and allergies and being flemmy? Dyspnea in young people is usually asthma or something pretty severe IIRC.

 

[michaelrack]

Can someone with more knowledge comment on this? No workup because a lot of cases are idiopathic, and if it wasn't severely limiting him and there's nothing in the history to indicate lung disease there's no point putting him through a battery of tests? That's what I thought at first glance.

PFT's/spirometry. Maybe CBC (at least H/H).

 

[michaelrack]

I always write down the PMHx as the patient is talking.

 

[evilbooyaa]

Depends on the complexity of the patient. If it's someone extremely complicated, I'll probably write down more. If it's a more simple HPI, based on what I've been told prior to going to the ED to admit, then I won't bother.

For SOAP notes I don't write until I get to the note. Overnight events are short enough I don't need to write them down.

 

[Owlie]

That's what I was thinking. Depends on the severity and what the patient thinks dyspnea actually is. Are we talking getting winded after running a mile when you think it should take 2? Is it just congestion and allergies and being flemmy? Dyspnea in young people is usually asthma or something pretty severe IIRC.

My mother has severe asthma. Maybe I am using the term wrong, however my condition is simply an almost constant inability to reach a plateau with my breath in. Simply running or jogging doesn't make me winded. There's no congestion involved that I can tell. It's actually diminished quite a bit this year.

 

[Owlie]

Can someone with more knowledge comment on this? No workup because a lot of cases are idiopathic, and if it wasn't severely limiting him and there's nothing in the history to indicate lung disease there's no point putting him through a battery of tests? That's what I thought at first glance.

It isn't severely limiting, but is quite uncomfortable. Studying has been sometimes hard with it. It was also hard to fall asleep during the peak occurrences. He also knows I have a long history of seasonal allergies.

 

[VenusinFurs]

It isn't severely limiting, but is quite uncomfortable. Studying has been sometimes hard with it. It was also hard to fall asleep during the peak occurrences. He also knows I have a long history of seasonal allergies.

You should probably see a primary care doc. Does your school have student health?

Getting away from medical advice, no one cares if you write stuff down a lot when talking to them. Don't do it in your standardized patient exams as much (at least in 1st and 2nd year) but yeah. You'll also kind of figure out what's important to write down and what isn't as time goes on.

If you're talking about a real patient scenario, the nerves really go away with time. That whole "I'm just a student I'm not supposed to be here" thing gets much better. I think it's impossible to not be a little nervous with graded SP exams.

 

[tantacles]

Ok, so in response to the original thread, one of the best ways to personalize note-taking is simply to let the patient know that you're going to be doing it. I completely agree with the pausing idea, that you can listen to the patient speak and write down what they say afterward, but you can then use summaries to make sure you're writing down what they said accurately.

For example:

MS1: Tell me a bit more about your headaches.

Patient: Well, they've lasted for about three weeks and it's just a huge throbbing on the right side of my head, and I've never felt anything like this before.

MS1 (while writing): All right, so for three weeks, you've had throbbing on the right side of your head and the pain is completely new to you. (Look up) How severe is the pain on a scale of . . ..

You get the picture. The repetition of what the patient says in different words, I've found, really helps to personalize the encounter and lets the patient know that you're listening closely.

 

[SpecterGT260]

My mother has severe asthma. Maybe I am using the term wrong, however my condition is simply an almost constant inability to reach a plateau with my breath in. Simply running or jogging doesn't make me winded. There's no congestion involved that I can tell. It's actually diminished quite a bit this year.

ok... well. preface: we arent supposed to (nor are we qualified) to be diagnosing or giving out healthcare advice.


That said... reach plateau? what are you defining as plateau. With dyspnea you feel like you are suffocating even when your airways are clear (1 presentation anyways). If you are jogging just fine it doesnt sound like dyspnea is the appropriate term.

 

[Donald Juan]

ok... well. preface: we arent supposed to (nor are we qualified) to be diagnosing or giving out healthcare advice.


That said... reach plateau? what are you defining as plateau. With dyspnea you feel like you are suffocating even when your airways are clear (1 presentation anyways). If you are jogging just fine it doesnt sound like dyspnea is the appropriate term.

Stop diagnosing/arguing semantics...you're not qualified to do either one.

 

[SpecterGT260]

Stop diagnosing/arguing semantics...you're not qualified to do either one.

If only I had said that 🙄 seriously do you need me to read it to you?

I just asked him what he meant by plateau. It is a term I am not familiar with and his story isn't adding up per what I currently know. There is nothing wrong with that

Fail, dude.... fail...

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[Owlie]

ok... well. preface: we arent supposed to (nor are we qualified) to be diagnosing or giving out healthcare advice.


That said... reach plateau? what are you defining as plateau. With dyspnea you feel like you are suffocating even when your airways are clear (1 presentation anyways). If you are jogging just fine it doesnt sound like dyspnea is the appropriate term.

I'm not attempting to be diagnosed lol
I'm just explaining my situation.

What I mean by reaching a plateau is, when you breathe in, you naturally reach a point where you feel 'satisfied,' for lack of a better term. When I breathe it, it can feel as though there's just a little bit more I can breathe in, and my body knows I'm not getting enough air in my lungs as I should, which causes very long yawns to sometimes occur.

Does that explain it a little better?

 

[SpecterGT260]

I'm not attempting to be diagnosed lol
I'm just explaining my situation.

What I mean by reaching a plateau is, when you breathe in, you naturally reach a point where you feel 'satisfied,' for lack of a better term. When I breathe it, it can feel as though there's just a little bit more I can breathe in, and my body knows I'm not getting enough air in my lungs as I should, which causes very long yawns to sometimes occur.

Does that explain it a little better?

Nor was I trying to diagnose. That why I said the first part. Talking about arbitrary symptoms are one thing. However discussing it with someone who has it can be seen as diagnostic and I wanted to avoid that. The point of my post was not to figure out what, if anything, you have. The point was to talk about why the doctor you described may have done what he did. The assumption is that a complaint of dyspnea needs thorough testing. But that assumption depends on accurate reporting of dyspnea among other factors. That was the point. Too many patients have expectations for testing and treatment when it may simply not be indicated regardless of what the patient self identifies symptoms as.

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[Mattchiavelli]

if you're worried the patient will think you're blowing them off by writing, say some thing like "you've got quite a bit going on, let me write down some notes while you talk so I make sure I get everything"

You don't have to write down EVERYTHING they say, just the high points as far as what could go into a review of systems or help you make a timeline of the history of their illness. Then you can go over your highlights with the patient and make sure you've gotten everything straight- sometimes the patient will then remember that they told you something wrong or out of sequence (hint- we ask the patient to repeat their story multiple times not because we don't want to read the chart but because if the story stays consistent we can probably take it at face value but if it changes every time they talk to someone you probably have to take it with a grain of salt)

As you get better some of your report-building history questions will actually provide you with useful clinical info

What kind of job do you have ----> education level, industrial exposures, baseline functioning
what do you do in your spare time --> baseline exercise tolerance and function
have any pets? -->animal exposures
who do you live with at home ---> can open up to need for domestic violence screen or calling CPS/APS, will be useful when you need to discharge the patient

remembering personal stuff about patients really does get you a lot of points with them.... remember they wouldn't be talking to you unless they had a life they wanted you to help them return to, so try to get to know what you're trying to return the patient to. Patients that feel comfortable with their doctors are more likely to reveal important information that is personal or embarrassing but clinically useful.

 

[Capltd29]

I know that as a scribe, the doc I was working with would sometimes ask me details of the HPI and PMH afterwards, if for no other reason than to clarify, since I was writing and he/she was talking, but more often than not, they always seemed to have it down pretty well without writing it.

 

[Owlie]

Nor was I trying to diagnose. That why I said the first part. Talking about arbitrary symptoms are one thing. However discussing it with someone who has it can be seen as diagnostic and I wanted to avoid that. The point of my post was not to figure out what, if anything, you have. The point was to talk about why the doctor you described may have done what he did. The assumption is that a complaint of dyspnea needs thorough testing. But that assumption depends on accurate reporting of dyspnea among other factors. That was the point. Too many patients have expectations for testing and treatment when it may simply not be indicated regardless of what the patient self identifies symptoms as.

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I know. I almost said that because of what Donald said. You're right. I don't know exactly why, but I should've asked many more questions.

Maybe 6 months after this I read a book called How Doctors Think by Jerome Groopman, M.D. It gave me an interesting perspective on what my physician may have been thinking, both right and wrong, and how I should've been my own advocate in asking questions and making sure he understood me.

In light of this subject, I'd actually recommend for any future physician to read that book.

 

[SpecterGT260]

well, donald is confused. Otherwise, gotcha 👍

 

[Bartelby]

If you are in a hospital setting much of the PMH is probably already in the system for you, as are the meds and allergies. Paste them into a note template and walk into the room with them, then confirm them with the patient and add anything else (there probably will not be much else, but get specific about anything else you want to know). For most inpatients that takes care of the PMH/allergies/meds immediately.

For the HPI as you see more patients and start being able to weave everything into a coherent story/picture it gets a lot easier to remember the details that matter. At an early stage in your training you do not know which details matter as easily and if you don't write them down they may not "stick." I would recommend when starting on a new service getting a note template that gives you some guidance about that specialty's HPI and ROS and taking lots of notes. As you get more comfortable you can transition away from that, as being able to have a more natural conversation with the patient both feels more comfortable and allows you to gather information more quickly. Still, have something on hand to jot down important names, phone numbers, or very important dates or numbers that might slip your mind.

It also helps to immediately walk out of the room to a computer and write everything down just after the interview (vs. waiting until you get some downtime later). Even when I take lots of notes I find that they aren't that necessary if I type the note up immediately.

 

[PikminOC]

I type my notes in front of the pt and check things with them to be sure I am not missing anything.

Otherwise, I would have to cut time with them to write the note separately.

This does not work every time, but it helps me stay on track in this litiginous society where the only thing that may possibly save you is your documentation.

 

[SpecterGT260]

I type my notes in front of the pt and check things with them to be sure I am not missing anything.

Otherwise, I would have to cut time with them to write the note separately.

This does not work every time, but it helps me stay on track in this litiginous society where the only thing that may possibly save you is your documentation.

Do you work outpatient or psych ward? This isn't always practical in other specialties

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[PikminOC]

Outpatient..and the patient has to deal with it if they want the extra time. Alot of them actually appreciate that they are able to make corrections as I will speak some of what I type.

 

[SpecterGT260]

Outpatient..and the patient has to deal with it if they want the extra time. Alot of them actually appreciate that they are able to make corrections as I will speak some of what I type.

No that's fine. It works well for outpatient. Many docs will enter notes right there during the encounter in outpatient clinics. Inpatient is a different story though

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[PikminOC]

Inpatient is a different animal in many ways. While the acuity is higher, the time crunch is also not as bad.

Inpt I would take copious notes. I had a form for intakes that I would fill out and dictate.