(M2) Consistently bad SOAP note grades from faculty, but clinicians love my notes

[smh343]

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So I 100% always get about 15-20% below class average on all our graded SOAP notes in our clinical-type classes. We upload them and some unknown faculty member grades them. They write feedback on each note when they give it back.

I always get marked off for weird, specific things, like not doing genitourinary exams or full neuro exams for patients with URIs. Or not asking exactly how many times per day a patient coughs. Or not warning an adult patient about a potential pediatric side effect. It's been about 15 straight graded notes all like this. I used to scribe for a couple years, and write ungraded notes in a rotation we have, and my physicians always loved my notes. It's super bizarre.

I've seen my friends' feedback which is nothing like mine. Usually they get automatic 100s despite missing many things. Is this something you can bring up to the school administration without sounding whiny? Am I maybe systematically doing something wrong?

Thanks!!

 

[sella.turcica]

Upload one of them notes here for our review.

 

[ciestar]

You cannot please everyone. You’ll notice as time goes on what one clinician likes, another hates.

 

[InternistDO]

Our clinical class SOAP notes were multipage epics, where every patient had every aspect of their physical exam and ROS completed, an exhaustive social history, a documented differential, and every little tiny thing was covered in the assessment and plan in great detail. They were, I **** you not, 4-5 pages each for simple complaints like "genital discharge" or "cough and fever". Comparing them to a real EMR note is like comparing The Iliad to a 6th graders Classical Studies essay. They were "perfect" notes, in the sense that they contained every little detail, but they were useless clinically because no one has time to write or read something like that.

My point is, you just have to play the game with preclinical professors, many of whom are long removed from the realities of clinical medicine. Ask your friends who get 100s how they write theirs, follow the format they use and forget about how to write a "real" SOAP note until 3rd year. At that point you can go back to writing real notes like you learned as a scribe and forget whatever they taught you in class.

 

[Chibucks15]

Our clinical class SOAP notes were multipage epics, where every patient had every aspect of their physical exam and ROS completed, an exhaustive social history, a documented differential, and every little tiny thing was covered in the assessment and plan in great detail. They were, I **** you not, 4-5 pages each for simple complaints like "genital discharge" or "cough and fever". Comparing them to a real EMR note is like comparing The Iliad to a 6th graders Classical Studies essay. They were "perfect" notes, in the sense that they contained every little detail, but they were useless clinically because no one has time to write or read something like that.

My point is, you just have to play the game with preclinical professors, many of whom are long removed from the realities of clinical medicine. Ask your friends who get 100s how they write theirs, follow the format they use and forget about how to write a "real" SOAP note until 3rd year. At that point you can go back to writing real notes like you learned as a scribe and forget whatever they taught you in class.

Literally today I had a resident react with a 'woah thats a hell of an HPI" because I followed school nonsense. You cant please everyone, just have the social intelligence to tell what to include and what not to. Goes the same with presentations of patients.

 

[deleted936470]

S = subjective = anything is fair game

 

[y123]

Don’t worry too much as long as you pass

 

[curbsideconsult]

A GU exam for a URI?? If I ever get a GU exam for a runny nose and cough I'm flipping the table and running out of there.

If these SOAP notes are to be focused, I would bring it up to the prof running the class because someone is teaching some of you very incorrectly. Focused notes should be just that. You should not be expected to do DREs for suspected conjunctivitis.

 

[smh343]

Our clinical class SOAP notes were multipage epics, where every patient had every aspect of their physical exam and ROS completed, an exhaustive social history, a documented differential, and every little tiny thing was covered in the assessment and plan in great detail. They were, I **** you not, 4-5 pages each for simple complaints like "genital discharge" or "cough and fever". Comparing them to a real EMR note is like comparing The Iliad to a 6th graders Classical Studies essay. They were "perfect" notes, in the sense that they contained every little detail, but they were useless clinically because no one has time to write or read something like that.

My point is, you just have to play the game with preclinical professors, many of whom are long removed from the realities of clinical medicine. Ask your friends who get 100s how they write theirs, follow the format they use and forget about how to write a "real" SOAP note until 3rd year. At that point you can go back to writing real notes like you learned as a scribe and forget whatever they taught you in class.

That's true, these aren't like real life. It's just frustrating that I'll get a 50% on my plan for nothing other than not warning an adult about pediatric side effects, while my friends get completion credit (who I help write their notes and we've compared our feedback - they're just as baffled as me). I know 1-2 other people who have the same issue as me, so I wonder if they assign graders by last name or something..

 

[longhaul3]

ROS: per HPI

 

[operaman]

Hard to say without a sample to review.

In the preclinical years (and later) there’s a real art to notes. Omitting the GU exam for a URI really only makes sense if the HPI and ROS revealed no complaints in that area. You could still include it in your exam but say you deferred it.

There’s also the issue that clinician notes generally suck. Resident notes suck even more. We write a LOT of bad notes for many reasons, but students should learn how to write a good one. It probably is trickier for people with clinical experience writing notes.

 

[NotAProgDirector]

ROS: per HPI

Just sayin', put that in an H&P and it instantly bills as a level 1, no matter what else you do.

 

[radsisrad]

Hard to say without a sample to review.

In the preclinical years (and later) there’s a real art to notes. Omitting the GU exam for a URI really only makes sense if the HPI and ROS revealed no complaints in that area. You could still include it in your exam but say you deferred it.

There’s also the issue that clinician notes generally suck. Resident notes suck even more. We write a LOT of bad notes for many reasons, but students should learn how to write a good one. It probably is trickier for people with clinical experience writing notes.

Are you referring to expectations for med students or real-life medicine?

Because if I were ever in a physician's office for a URI and (s)he performed a GU exam, I'd raise some eyebrows. And attendings don't have time for that, anyway.

 

[operaman]

Are you referring to expectations for med students or real-life medicine?

Because if I were ever in a physician's office for a URI and (s)he performed a GU exam, I'd raise some eyebrows. And attendings don't have time for that, anyway.

More for med students though technically real life as well. Really it would just be if your ROS picked up another problem and only if the patient consented to the exam of course. If there’s no time and it’s not suggestive of something emergent you can just advise the patient to come back for a close follow up appointment to address something that may be a serious issue.

 

[FutureInternist]

Just sayin', put that in an H&P and it instantly bills as a level 1, no matter what else you do.

Unless you bill by time, which is SO much easier than trying to hit X organ systems with Y components in each.
You end up asking about BS stuff that has nothing to do with HPI just to get the billing to a higher level.
I much rather spend that time reviewing prior admit, doing med rec, calling consults, and following up on the previous pt’s CT and hence update my note with the latest info

 

[radsisrad]

More for med students though technically real life as well. Really it would just be if your ROS picked up another problem and only if the patient consented to the exam of course. If there’s no time and it’s not suggestive of something emergent you can just advise the patient to come back for a close follow up appointment to address something that may be a serious issue.

Reasonable.

My view on this subject of this thread is that, sure, when you're done with med school/residency, you (referring to those in clinical specialties) will be writing notes that are a few lines long, with practically broken English. That's how strapped for time doctors are now, like it or not. But as a med student, you don't yet know enough to cut corners, just as a novice weightlifter should never do cheat sets. This is why med students shouldn't have more than three or four pts to carry at a time. Take the time to learn what's important, and - in time - you'll be able to trim the fat.

 

[LucidSplash]

Just sayin', put that in an H&P and it instantly bills as a level 1, no matter what else you do.

ROS: A comprehensive, more than 12-point review of systems was performed and was negative except as noted in the HPI.
👍
It’s in my Epic Template for all followups. New patients get the checkbox one from their intake paperwork transcribed Into the notewriter ROS utility.

 

[NickNaylor]

I had this happen all the time in medical school. While I agree with others that everyone is looking for something different and it can be impossible to please everyone, I do think that it's a good task to try and take the feedback openly and take useful critiques away from it if you can. Style-related things like formatting, highly specific verbiage, etc. are generally not helpful. The feedback you provided doesn't seem onerous to me (except not documenting a GU exam - rarely is someone going to do a GU exam, though you could still include it in your note and simply write "deferred"). Working as a scribe and working as a clinician are two very different things. Translating/transcribing someone else's work is not the same as coming documenting that you actually did the work, and in medical school specifically you will likely be expected to write unrealistically long and detailed progress notes. But the whole point is that you will come to learn what is and is not necessary to ask about and can leave that information out if you don't feel it's pertinent. It's unsurprising to me that starting off with that approach as a pre-clinical student is going to be viewed negatively.

 

[operaman]

Reasonable.

My view on this subject of this thread is that, sure, when you're done with med school/residency, you (referring to those in clinical specialties) will be writing notes that are a few lines long, with practically broken English. That's how strapped for time doctors are now, like it or not. But as a med student, you don't yet know enough to cut corners, just as a novice weightlifter should never do cheat sets. This is why med students shouldn't have more than three or four pts to carry at a time. Take the time to learn what's important, and - in time - you'll be able to trim the fat.

Agree 100%

The clinical year corollary would be students who say things in presentations like “_____ was normal” when they may have no idea what normal is. They hear this from more senior people speaking to each other, but fail to recognize that nobody believes they know what that is. Hell, If I had a nickel for every call I’ve gotten from an intern or junior resident saying a patient was “stable” when after a few probing questions were anything but!

Takes a lot of time to trim the fat without losing the meat.

 

[NotAProgDirector]

Unless you bill by time, which is SO much easier than trying to hit X organ systems with Y components in each.
You end up asking about BS stuff that has nothing to do with HPI just to get the billing to a higher level.
I much rather spend that time reviewing prior admit, doing med rec, calling consults, and following up on the previous pt’s CT and hence update my note with the latest info

Yes, but. If you bill based by time, that time needs to be face to face with the patient, or directly on the ward. If you're calling consults from an office or work room, it doesn't count. I know this because we were subject to a large medicare fraud judgment/settlement on this exact issue. Using time billing is not so easy. It's actually much easier to bill based on elements. And you only need the ROS for admission -- each of the daily progress notes doesn't need it at all.

ROS: A comprehensive, more than 12-point review of systems was performed and was negative except as noted in the HPI.
👍
It’s in my Epic Template for all followups. New patients get the checkbox one from their intake paperwork transcribed Into the notewriter ROS utility.

Sure. And if you get sued for medmal, the lawyers can ask you "So, you clearly asked the patient about whether they had new itching in their left eyeball, so what did they say?" Our risk management group has highly recommended not including this statement. Makes it easy to bill, but hard to defend against since you don't really know what you did.

 

[FutureInternist]

Yes, but. If you bill based by time, that time needs to be face to face with the patient, or directly on the ward. If you're calling consults from an office or work room, it doesn't count. I know this because we were subject to a large medicare fraud judgment/settlement on this exact issue. Using time billing is not so easy. It's actually much easier to bill based on elements. And you only need the ROS for admission -- each of the daily progress notes doesn't need it a

I add the time spent in talking to pt about upcoming tests, results of previous tests, time spent with Case Management during rounds (which is done at nurses station) etc.

I just meant that the time I don’t spend asking about their itchy left eyeball, is used for more meaningful and clinically relevant data gathering.

I once got a “ding” for not asking about family hx and was told it could not be coded a certain level... except that the pt was like 75.....WTF
What possible bearing could that have in this age group 😡

 

[aafisahar]

Unless you bill by time, which is SO much easier than trying to hit X organ systems with Y components in each.
You end up asking about BS stuff that has nothing to do with HPI just to get the billing to a higher level.
I much rather spend that time reviewing prior admit, doing med rec, calling consults, and following up on the previous pt’s CT and hence update my note with the latest info

But you if you get audited on time and it seems implausible based on your workload, you'll get ****ed by Medicare. Every patient I see in clinic (~10-12/half day in fellowship) is billed at a level 4 or 5. If I did time based, I'd get reamed in an audit.

 

[CherryRedDracul]

What year are you, OP? If you're in your preclinical years with some clinical exposure like they did at my school, the faculty expects full SOAP notes because they want to know that you're good at gathering data.

Once you're in your clinical years, then you have to know what is relevant to the chief complaint and what can be omitted.

Two different scenarios require two different things.