Not Allowed to write notes on hospital rotations!

[HooliganSnail]

Ok, so i started my core clerkship this week and found out that students are not allowed to write up any patients, or any other notes of any kind! I'm going to be there the entire year! Writing an adequate note is one of the most important skills a doctor should learn in medical school and I'm not allowed to do it? Any thoughts or advice would be appreciated.

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[Dissected]

It would take a lot of self-discipline, but you could bring a notebook and write your own notes for practice. Not quite the same, but it will get you thinking in an organized fashion and you can use them as your notes for oral reports on rounds. I did this on my internal med where we weren't allowed to write notes/orders and I was glad after the month was over.

 

[werd]

the policy varies from place to place, but at most hospitals, med student notes aren't part of the official medical record. at some places, you can put them in the chart with a big "MS3 note" or something at the top, but at other hospitals not. even if you aren't leaving notes for the pt's chart and medical record, you should still write/create them. they will be a template from which to present at rounds and good practice for the future.

 

[235009]

take a blank progress note sheet and write a note. it's hard to force yourself to do this when you know it doesn't count but you need to take ownership of your education. make sure you show the note to an intern or senior resident ...not only will you get credit for going above and beyond you'll also get some helpful tips.

 

[MrBeauregard]

Ok, so i started my core clerkship this week and found out that students are not allowed to write up any patients, or any other notes of any kind! I'm going to be there the entire year! Writing an adequate note is one of the most important skills a doctor should learn in medical school and I'm not allowed to do it? Any thoughts or advice would be appreciated.

I would print out a few copies of your favorite note sheet and keep them in your white coat. After you see a patient, take a few minutes and write a quick note. Even though it won't be included in the chart and your attendings won't sign-off the note, you'll still get used to thinking correctly. It also doesn't matter that it will be paper and you'll be using EMR by the time you practice, you'll still be getting practice writing notes every day. You might could find a resident or cool attending that would be willing to read your note and give you a little advice/feedback on it.

 

[grotto]

Wow, I need to get to this hospital... I have been on rotations for 2 weeks and write progress notes every day on patients I follow. I also do orders, admit H&P's and discharge summaries. The resident and atteding then edit and electronically sign my notes. It would be nice not to be doing so much paperwork. Is this a non-EMR hospital?

 

[235009]

Wow, I need to get to this hospital... I have been on rotations for 2 weeks and write progress notes every day on patients I follow. I also do orders, admit H&P's and discharge summaries. The resident and atteding then edit and electronically sign my notes. It would be nice not to be doing so much paperwork. Is this a non-EMR hospital?

this is a silly thing to say. the more you get to do as a med student the better because you will have those skills when you enter residency where you'll be expected to do these things and there will be one fewer person looking over your shoulder.

i would actually advise med students or future med students against rotating at this hospital or attending this med school.

 

[grotto]

i would actually advise med students or future med students against rotating at this hospital or attending this med school.

Now THAT is a silly thing to say. We learned how to write notes in second year at my school and it helps that the system I am in has standardized EMRs for outpatient and inpatient with easy to use templates for formatting various types of progress notes, orders, and such - so it isn't hard for me. The system the OP is in might not have that, and they also might not want med students writing pt notes that then have to be transcribed for billing.

 

[p30doc]

They told us we were not to write in the chart. We had to use different colored paper to write our notes and temporarily place them in the chart. I immediately got scolded for doing this by the residents on day one. So there after I wrote on the normal progress note paper. The residents edited it (usually minimally) and signed it then the attending edited it and signed it too. So what the official line is and what the reality is can be very different things.

This ending being great for me I learned how to write good progress notes and h&ps which varies greatly based on service/resident/attending/phase of moon. On some outpt rotations with emr I was unable to write/enter notes. I thought this was bs. You get a lot more out of each patient when you are forced to sit there and think about what you want to write, knowing everyone else following the patient would be reading it. Writing notes is a skill that needs to be honed imo.

 

[Deepa100]

This really bugs me. Ok, don't train any future docs by not letting them do anything that matters and oh by they, also hire the ER scribes. There is no respect for teaching in this country! The reason we train doctors the longest is because no one really has time to teach except a precious few who make the effort! We are supposed to watch, shut up and learn.

 

[HooliganSnail]

you talk about your rotations like they are a bad thing, your hospital sounds wonderful.

 

[HooliganSnail]

Wow, I need to get to this hospital... I have been on rotations for 2 weeks and write progress notes every day on patients I follow. I also do orders, admit H&P's and discharge summaries. The resident and atteding then edit and electronically sign my notes. It would be nice not to be doing so much paperwork. Is this a non-EMR hospital?

You talk about your rotations like they are a bad thing, your hospital sounds wonderful, maybe we can trade

 

[HooliganSnail]

This really bugs me. Ok, don't train any future docs by not letting them do anything that matters and oh by they, also hire the ER scribes. There is no respect for teaching in this country! The reason we train doctors the longest is because no one really has time to teach except a precious few who make the effort! We are supposed to watch, shut up and learn.

I could not agree more. Very frustrated right now

 

[HooliganSnail]

Now THAT is a silly thing to say. We learned how to write notes in second year at my school and it helps that the system I am in has standardized EMRs for outpatient and inpatient with easy to use templates for formatting various types of progress notes, orders, and such - so it isn't hard for me. The system the OP is in might not have that, and they also might not want med students writing pt notes that then have to be transcribed for billing.

Everybody learns how to write a note in second year, but its not like riding a bike, it takes practice and experience to be able to write a concise and informative note. When you consider that the crux of most malpractice suits rests completely on the SOAP note the doctor wrote, would you want to just bank on what you learned 2nd year as being more than adequate education?

 

[DirtyNetter]

Write your note anyway, use it to present your patients, and keep it in your pocket for later in case your attending asks you for previous data.

 

[QuaerensIntelle]

Everyone will tell you different things about writing notes. Just write your own on a blank piece of paper or type them up and print them on notepad. Have your senior look at a few a week and go over it with you if they are willing. Most of the residents I've met are super nice and will be more than willing to help if you let them do it when they have some free time. There's really no specific benefit of putting your own physical note in the chart. Also, when you meet to talk about your performance with your attending, give them some examples of your notes. Just say that you thought it might help them write your eval. You'll look like a very organized student.

 

[genswim24]

Write your note anyway, use it to present your patients, and keep it in your pocket for later in case your attending asks you for previous data.

Good advise. This is what I did for places where the hospital didn't accept our notes. It kept my patient presentations precise and on point.

 

[Substance]

I guess this means you have to go into a field that doesn't write inpatient notes: radiology, pathology, radiation oncology, anesthesiology or derm. Oh the humanity.

 

[nlax30]

Where am I'm training we had to institute the same policy last year. Was told its actually a CMS policy (if that's truly accurate) so if that's true then it's going to be like this more and more places as they come into "compliance". Blame the medical-legal system.....

We have pink sheets the med students can write on but they are not part of the medical record. We had one of our hospital CMS inspections not too long ago and this was a fairly big issues, no students writing in the chart.

I don't really agree with it but it is what it is.

 

[Dwindlin]

Where am I'm training we had to institute the same policy last year. Was told its actually a CMS policy (if that's truly accurate) so if that's true then it's going to be like this more and more places as they come into "compliance". Blame the medical-legal system.....

We have pink sheets the med students can write on but they are not part of the medical record. We had one of our hospital CMS inspections not too long ago and this was a fairly big issues, no students writing in the chart.

I don't really agree with it but it is what it is.

Billing issue from the CMS. They dictate that the only portion that can be documented by a medical student and still be billed for is like the ROS and I believe one other thing (escapes me atm).

 

[nlax30]

Billing issue from the CMS. They dictate that the only portion that can be documented by a medical student and still be billed for is like the ROS and I believe one other thing (escapes me atm).

Yea, I remember something along those lines. At one point they were trying to still allow it along the lines of Treating the medical student note as being written by a scribe but that didn't fly either apparently and so we just had to outright say no student writing in the chart.

 

[Dwindlin]

We are allowed to write daily progress notes, however an entirely separate note must be entered by the resident.

 

[phantomx87]

I am at a military hospital right now... The EMR system is atrocious, but I am allowed to write a note (and input orders, admit, transfer, etc), but everything has to be co-signed by a resident and subsequently counter-signed by my attending.

I do agree, however, that there is a huge benefit to writing notes on a regular basis. The stuff they teach you second year is garbage IMHO. It takes time, practice, and plenty of feedback in order to learn how to write a good, informative, and concise note.

Also greatly varies by service (as I've seen so far). Psych notes are much much more detailed and longer than pre/post-op notes, but both require their own levels of sophistication and finesse.

 

[shiftingmirage]

If/when you write your notes by hand, at some point, find a resident and say, hey, can we go over my note?

 

[StephenMaturin]

Where am I'm training we had to institute the same policy last year. Was told its actually a CMS policy (if that's truly accurate) so if that's true then it's going to be like this more and more places as they come into "compliance". Blame the medical-legal system.....

We have pink sheets the med students can write on but they are not part of the medical record. We had one of our hospital CMS inspections not too long ago and this was a fairly big issues, no students writing in the chart.

I don't really agree with it but it is what it is.

When I was a scribe pre-medical school my note was part of the medical record. It's hilarious that now that I'm a medical student I'm no longer allowed to do that.