Question about notes/h+p's

[greenbean]

im not sure if i should put this in the intern but oh well

i had quick question regarding documentation and would like some advice, i created templates for h and p's and soap notes that saved me alot of time on my sub-i rotation and other electives and thought about using them during my intern year medicine , i still print them on the hospital paper so they look like i typed them on hospital forms,

i emailed these to the chief res just to make sure it would be ok to use a few days ago. he emailed me back another soap note that the other residents use and told me it would be better to use that instead because "too many forms" would get confusing or whatever and that the h and p needed to hand written

i looked at the form that he sent me and it was really bad, if you want to copy and paste labs or meds it gets all messed up, i think they tried drawing in lines and pasting the hospital logo and then just print the note like that

do you think i should use my templates(which i think are more concise and organized, as well as neat) or just suck it up and do what im told?

thanks,
greenbean(an intern constantly trying to reduce unnecessary work)

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[jennyboo]

The best way to do things the way you want, is to simply do it without asking. So you probably should simply have started your internship with your own template and not asked.

But since you already asked, I would suggest using the hospital's template for a period of time until you get familiar enough with the system to figure out which rules you can get away with bending. Wait a couple months, then switch your template and don't ask anyone for permission.

 

[Winged Scapula]

Starting off your intern year by ignoring advice from your Chief resident is bad form. Even if the advice isn't good. You'll brand yourself a trouble-maker and first impressions count - if you get a bad one to start off with, it will haunt you forever (believe me, because ONCE during my intern year [in the old, pre 80 hr week days] I asked if I could go home because it was my birthday, it was 9 pm and my new sexy boyfriend was waiting for me. I became ever after branded as the resident who "always" wanted to go home "early".)

The issue about too many forms may be even more complicated. Many hospitals have Form Committees and all new forms have to be approved before being placed in the hospital medical record. I know our Renal fellows had an H&P/Consult form they used and it had to be approved before they could. Your hospital may be more lax and the current form used is something that a resident long ago came up with and its just become "standard".

At any rate, I agree with jennyboo. Start off the year using the sanctioned form, see if you can get away with using yours and even perhaps make some moves to get your form as the standard. But wait a few months before making any rash moves...like ignoring "advice" or replenishing a low potassium!

 

[BADMD]

do you think i should use my templates(which i think are more concise and organized, as well as neat) or just suck it up and do what im told?

There is no question. Use their form, their way...at first. Then, after a month or so, make improving the form a quality improvement project and improve the form. Since things are going to be done differently there, getting a month or two under your belt will further help you refine what you are doing. If you can collect examples of problems related to their form from other people, you make your case stronger.

 

[greenbean]

i thought about not showing my template and just using it on my own but at the orientation they told us to show it to the chiefs first, so my guilty conscience got the better of me i suppose

handwriting the h and p(especially on medicine) is going to be painful

thanks for sharing the story kimberlicox and everyone else for the input