PE/CS-note taking

[storePQ]

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Hello everyone,
I was wondering if you tell me what strategy you used to take a note while interviewing the patient. I heard that eye contact is very important but I just don't know what strategy I can use to take a note and eye contact at the same time. What if I ask one question and wait until patient finished then write a note and then ask another question.. I can use this technique but it takes time. If you just listen and write later..I think it is impossible to remember every thing. Please help.

 

[Osteoimperfecta]

Hello everyone,
I was wondering if you tell me what strategy you used to take a note while interviewing the patient. I heard that eye contact is very important but I just don't know what strategy I can use to take a note and eye contact at the same time. What if I ask one question and wait until patient finished then write a note and then ask another question.. I can use this technique but it takes time. If you just listen and write later..I think it is impossible to remember every thing. Please help.

Some ask for permision to write notes, but I heard it will still count against you. I have heard you are better of trying to memorize the bulk of what they are saying without writting much during the encounter. Missing few history details is less destructive than missing eye contact and CIS type points IMO.

 

[storePQ]

Thank you Osteoimperfecta. I think it is very difficult to remember everything without writing. Any one have a strategy for this please. Thanks

 

[storePQ]

Is note taking can affect your score..any advice please

Is there any one here who took note and pass? If you didn't take a note how can you remember every information for patient note..

Thanks

 

[thedon35]

Well I hope note taking doesn't screw you... I took brief notes down... like the main component of what they said. I haven't gotten my grade back yet though!! I think it is impossible to remember everything they said and you sure don't want to write something in your note that they NEVER said, because that will definitely cost you.

 

[storePQ]

Thank you very much thedon35. I think I will take a note too. On the sample video, I didn't see the person taking any note and only did little conversation. I can do it if I didn't ask a detail question like the sample video; otherwise I will definitely take a note whatever happens.

Thank you again

 

[cabinbuilder]

Is note taking can affect your score..any advice please

Is there any one here who took note and pass? If you didn't take a note how can you remember every information for patient note..

Thanks

I went to LECOM and we have a class that is similar to the PE to prepare us.
We were told to take minimum notes and have the 7 components

CC
Hx of Chief complaint
Medicines
Allergies
any pertinent surgeries relative to the chief complaint
Medical history
Physical exam
Assessment/Plan

Remember that you can touch the patient and do your physical exam while you are talking with them. You can give the patient and idea what your diagnosis should be and then the plan.

It sounds worse than it is. For example: I had a guy in obvious belly pain - probably appendicitis. Was pushing on his belly for the exam and was quick: ever had surgery on your belly, any major medical problems like HTN, DM, Crohn's, do you still have your appendix, etc. Any medicines: NO, any allergies to meds: NO How long as your belly hurt? always in the same region, etc.

So I said you have an emergency, I think its your appendix. We need to send you to the hospital, I will make arrangements - then stepped out of the room and wrote my note.

I was in there maybe 5 minutes. You have 15 mintues total..


As long as you touch the patient, act like you know what you are doing, listen to the answers and ask the questions you will be good.

Hope that helps

 

[thedon35]

I just found out I passed by the way and I took a decent amount of notes during the encounters.

 

[storePQ]

I just found out I passed by the way and I took a decent amount of notes during the encounters.

Thank you very much for the update and congratulations!