M3 needs advice re medicine rotation

[quixote1974]

Hi, I'm a 3rd year student on medicine. The area I need to improve is to better figure out what are the pertinent issues that I need to include in my soap note and tell verbally to the team. When we are running behind, my intern will ask me to go see a patient, who I will won't always be familiar with. When I get to the patient, I have a hard time sifting through the chart, and figuring out what relevant things I need to tell the intern and the attending. I just get bogged down by the chart. I check the orders, read the dictated H&P, and go through the progress notes. I take notes to myself as I read, but I find that my notes to myself include way too many details and not the pertinent things the attending and the intern need to know. I find that because of this, I don't always finish my note or am prepared to answer when the intern or the attending comes by. Sorry if this is a general question, but can someone offer any feedback?

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[hotbovie]

I'm assuming you are talking about a patient who is not just newly admitted to the service. If so, you should be vaguely aware of the basics from rounds on previous days (ie was the pt admitted for CHF, GI bleed, etc). You should also have a sense for if the pt has been improving, staying the same or getting worse during the stay.

So with that in mind, go read the H&P, and the previous day's note. (It's not necessary to go thru the whole chart ) Then you'll know what areas to focus on when you go see the pt. When you examine the pt, do a quick focused exam. Always make sure that pt is tolerating whatever kind of diet they have and that urine/gas is moving, and that there is no new pain, and that old pain is improving. (YOu probably know by now that pts often won't volunteer things) Then look at the vitals, I&0 and labs. I think a key with these things on a new pt is also to check the values from previous days, so that you know what the trend is (eg you find a Cr of 2.5....is that new or is it an improvement from 2.8, or perhaps it's the pts baseline). Also look up any other xray, echo, CT results if there are new test from those. It's probably only necessary to go through the previous days orders so that you can asertain what needs to be looked up and make sure it's all done

Then, write the note. You might start by using the previous day's note as a guide for which issues need to be addressed, and add any new issues you discovered. For example, a pts BP might be stable but there may be electrolytes that need replacing today.

For the presentation, take your cue from the residents and attending as far as the level of detail that needs to be included. If not much has changed with the pt, you may only need to say that he/she is doing well, and read the vitals and pertient labs (eg you'd be following the HCT for a GI bleeder, and you'd want to make sure lytes are OK for a pt on dig)

If you are being asked to see/present a new pt, it's often quicker to make a copy of the H&P and present from that (don't just read it, however, but refer to it). Your note could take the cue from the plan section of the H&P, only focus on areas that needed intervention, plus any new complaints the pt has.

Hope this helps! It just takes some experience to develop a routine.

 

[ckent]

Whenever I would pick up a pt mid-stay, I would read their original H+P (usually the admitting h+p is the most comprehensive at the hospitals that I have worked with, but I have worked with some interns who have such bare-boned H+Ps that the ER H+P becomes a more valuable resource (ER's sometimes do a better physical exam then the interns)), and their assessment and plan from the last couple of days. If the SOAP notes are decent, the A+P should provide you with all of the relevant issues of what needs to be done, what the pt has, what lab values need to be reported to the attending, etc. Also check the most recent labs, and whatever was not included in the previous day's soap note should probably be put in your soap note. Your first day's soap note will probably be longer then it needs to be, and you might end up reporting some things during rounds that the attending doesn't need to know the first day, but I never thought that was that big of a deal since everyone should know that you just picked up the pt and don't know what they do or don't know. I once tried giving a whole H+P to an attending whose H+P notes were already in the chart. There is always reading up on the pt and then asking whoever was previously taking care of the pt too of course.