Resident: don't write notes on my patients!

[VincentAdultman]

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Has anyone else dealt with this? The residents on my service have forbidden us to write progress notes on their patients. Apparently this is due to us writing erroneous findings and A/P's and opening the door for litigation.

But the residents have to read and sign off on all MSIII notes. It seems to me to be a simple "agree with above" followed by additional findings/reccomendations (if any) and removing anything that is wrong. Oh, and shouldn't we get practice writing these and doing the whole "clinical reasoning" thing? I mean, I'm pretty sure I'm not going to be able to suddenly write a good SOAP note on my first day of residency.

But that's just me.

 

[(nicedream)]

Has anyone else dealt with this? The residents on my service have forbidden us to write progress notes on their patients. Apparently this is due to us writing erroneous findings and A/P's and opening the door for litigation.

But the residents have to read and sign off on all MSIII notes. It seems to me to be a simple "agree with above" followed by additional findings/reccomendations (if any) and removing anything that is wrong. Oh, and shouldn't we get practice writing these and doing the whole "clinical reasoning" thing? I mean, I'm pretty sure I'm not going to be able to suddenly write a good SOAP note on my first day of residency.

But that's just me.

Maybe if you hadn't screwed up this wouldn't have happened.

 

[drRumi]

Maybe if you hadn't screwed up this wouldn't have happened.

typical response from someone who has already forgotten that they were a 3rd year a few years ago and completely clueless and had to learn at some point. or wait...maybe nicedream came out of the womb writing perfect SOAP notes. it gets so incredibly tiring to have idiot residents tell medical students that "if you hadn't screwed up this wouldn't have happened". just a few years ago you were that student that screwed up. try being a little helpful instead of an idiot.

 

[lvspro]

Has anyone else dealt with this? The residents on my service have forbidden us to write progress notes on their patients. Apparently this is due to us writing erroneous findings and A/P's and opening the door for litigation.

But the residents have to read and sign off on all MSIII notes. It seems to me to be a simple "agree with above" followed by additional findings/reccomendations (if any) and removing anything that is wrong. Oh, and shouldn't we get practice writing these and doing the whole "clinical reasoning" thing? I mean, I'm pretty sure I'm not going to be able to suddenly write a good SOAP note on my first day of residency.

But that's just me.

This is wierd. I thought that the only medical students whose documentation counts is a sub-I, and I think thats institution specific. btw, this is not opinion, I've asked about the legal ramifications of ms notes and had a few attendings say the same thing. At the places I'v worked, the residents did the seen n agree thing at the bottom, and then made adjustments like "no murmur auscultated" etc... and then cross out any erroneous findings in my our notes. Also, in the A/P, you should always put a ? before each Dx, and each recommendation. It indicates that you need to discuss w/someone w/seniority. Once again, I think the litigation thing is crap, your note doesnt count until you get a seen n agree on it.

btw, as abrasive as it may have been presented, the dude above has a point. It's important to get into the habit of good documentation, and if you do have an interesting finding, then you should be pretty sure you can reproduce it for a resident, or attending. If you write rhonchi, then you better darn well know what rhonchi sound like. Either way, I'm sure you know this

 

[fuegorama]

typical response from someone who has already forgotten that they were a 3rd year a few years ago and completely clueless and had to learn at some point. or wait...maybe nicedream came out of the womb writing perfect SOAP notes. it gets so incredibly tiring to have idiot residents tell medical students that "if you hadn't screwed up this wouldn't have happened". just a few years ago you were that student that screwed up. try being a little helpful instead of an idiot.

Even worse, I think he is an MSII.
Bad form.

 

[(nicedream)]

typical response from someone who has already forgotten that they were a 3rd year a few years ago and completely clueless and had to learn at some point. or wait...maybe nicedream came out of the womb writing perfect SOAP notes. it gets so incredibly tiring to have idiot residents tell medical students that "if you hadn't screwed up this wouldn't have happened". just a few years ago you were that student that screwed up. try being a little helpful instead of an idiot.

I was just kidding.

 

[(nicedream)]

Even worse, I think he is an MSII.
Bad form.

Haha, obviously my sarcasm was lost. Oh well...

 

[fuegorama]

This is wierd. I thought that the only medical students whose documentation counts is a sub-I, and I think thats institution specific. btw, this is not opinion, I've asked about the legal ramifications of ms notes and had a few attendings say the same thing. At the places I'v worked, the residents did the seen n agree thing at the bottom, and then made adjustments like "no murmur auscultated" etc... and then cross out any erroneous findings in my our notes. Also, in the A/P, you should always put a ? before each Dx, and each recommendation. It indicates that you need to discuss w/someone w/seniority. Once again, I think the litigation thing is crap, your note doesnt count until you get a seen n agree on it.

Agree with above. 😉
In lieu of the "?" we were told to write "consider" before each a/p point. It lets everyody off the hook and I think reads pretty well.

 

[robotsonic]

I think the belief that the MS's notes don't count legally is a myth. An attending once corrected me on this. Apparently whatever is in the chart can be used in court, regardless of whether the med student wrote it.

If you aren't completely sure about a physical finding or about the A/P, then wait to speak to the resident before you finish your note. Then you still get the practice of going through the case and creating your own A/P, but you also please the resident by only writing down what he/she agrees with.

 

[lvspro]

I think the belief that the MS's notes don't count legally is a myth. An attending once corrected me on this. Apparently whatever is in the chart can be used in court, regardless of whether the med student wrote it.

Like I said, I've had a few attendings tell me this. One was a brilliant neurologist who spends a day a week in court. Even so, until we see it in legal speak documentation, everything is hear-say. I wonder where we could find a definitive source.

Since we're on the topic, I once heard (again, hear-say) an attending discuss the rate of picking up murmurs, and the breakdown was MS3>MS4>R2>cardio fellow 😱
I thought about this for like... a minute, and then decided it may not be so off the wall. As you move up the totem pole, you have less time, and depend on the juniors for the daily grind of pt care. Hence, as an MS3, you get 1-3 pts at first, and have so damn much time to spend that it's likely you can pick upmore subtle findings. The question is whether or not you know what it is you're hearing. Either way, a resident should be able to hear, and document that it was indeed there. I guess this is the point where we go back to the original idea that an MS3 note doesn't count.

 

[Samoa]

Agree with above. 😉
In lieu of the "?" we were told to write "consider" before each a/p point. It lets everyody off the hook and I think reads pretty well.

We were told specifically NOT to do this, but instead to make a decision about what we think it is, and write a plan for what we think should be done about it, present our findings and assessment/plan to the intern/resident/attending for approval or alteration, and learn from any errors we've made in workup or judgment while we still have someone to correct us.

Since most med students hate making mistakes more than just about anything else, this helps to make the lessons memorable. No insults or demeaning comments necessary.

Everyone supervising us knows that these are our instructions, and knows that it's incumbent upon them to read our notes before signing off on them, or else to simply cosign ours and write a separate note documenting their own findings and assessment/plan.

 

[Adcadet]

We were told specifically NOT to do this, but instead to make a decision about what we think it is, and write a plan for what we think should be done about it, present our findings and assessment/plan to the intern/resident/attending for approval or alteration, and learn from any errors we've made in workup or judgment while we still have someone to correct us.

Since most med students hate making mistakes more than just about anything else, this helps to make the lessons memorable. No insults or demeaning comments necessary.

Everyone supervising us knows that these are our instructions, and knows that it's incumbent upon them to read our notes before signing off on them, or else to simply cosign ours and write a separate note documenting their own findings and assessment/plan.

Exactly how it has been done on my rotations.

And yeah, I picked up more murmurs than my (senior) residents on peds, though they were all 1/6 or 2/6 innocent flow murmurs. It helps to have 4 or fewer patients and not supervising two students and an intern.

 

[drRumi]

Exactly how it has been done on my rotations.

And yeah, I picked up more murmurs than my (senior) residents on peds, though they were all 1/6 or 2/6 innocent flow murmurs. It helps to have 4 or fewer patients and not supervising two students and an intern.

sorry, i know this is completely off topic and i apologize for highjacking the thread. Adcadet, do you by any chance know of some decent sites to hear murmurs and help recognize them? I am assuming that if you can hear 1/6 and 2/6 murmurs on peds, you must be the freakin shizz when it comes to murmurs. I am horrible with picking up murmurs. 🙁

 

[sacrament]

sorry, i know this is completely off topic and i apologize for highjacking the thread. Adcadet, do you by any chance know of some decent sites to hear murmurs and help recognize them? I am assuming that if you can hear 1/6 and 2/6 murmurs on peds, you must be the freakin shizz when it comes to murmurs. I am horrible with picking up murmurs. 🙁

Check out http://www.blaufuss.org/. I think that's it... the site seems to be down right now, but check it out later. Recognizing murmurs and extra heart sounds just takes a lot of practice.

 

[labangel]

This could also have to do with JHACO. Last year during my medicine rotation the hospital I was at was under review soon and we were told not to put our notes in the charts. But, we were still expected write our notes to get feedback.

And I know that our notes count in court because, during my psych rotation, one of my notes was read into the court record while we were trying to get a patient certified.

 

[drRumi]

Check out http://www.blaufuss.org/. I think that's it... the site seems to be down right now, but check it out later. Recognizing murmurs and extra heart sounds just takes a lot of practice.

right on ! 👍

much appreciated.

 

[RustNeverSleeps]

Has anyone else dealt with this? The residents on my service have forbidden us to write progress notes on their patients. Apparently this is due to us writing erroneous findings and A/P's and opening the door for litigation.

But the residents have to read and sign off on all MSIII notes. It seems to me to be a simple "agree with above" followed by additional findings/reccomendations (if any) and removing anything that is wrong. Oh, and shouldn't we get practice writing these and doing the whole "clinical reasoning" thing? I mean, I'm pretty sure I'm not going to be able to suddenly write a good SOAP note on my first day of residency.

But that's just me.

I think a lot of this has to do with hospital policy. I have never not been allowed to not put progress notes in a patient's chart (it would be nice to have a break sometimes though!). However, at a couple hospitals I rotated through, med students were not allowed to include their H&Ps in patient charts, although writing the H&P was a mandatory course requirement. The reason given is litigation, and I think it is legitimate. Med students often do the most thorough H&Ps (and often progress notes) and may include "little" things that residents and attendings do not. However, if anyone -- including the med student -- writes down a potential problem in the chart, it then has to be worked up and followed up on, or else the hospital risks legal consequences, particularly if there is a bad outcome. Perhaps your hospital, resident, or department has been burned by this before, which could explain why they are extra careful about student contributions in charts.

 

[VincentAdultman]

I think a lot of this has to do with hospital policy. I have never not been allowed to not put progress notes in a patient's chart (it would be nice to have a break sometimes though!). However, at a couple hospitals I rotated through, med students were not allowed to include their H&Ps in patient charts, although writing the H&P was a mandatory course requirement. The reason given is litigation, and I think it is legitimate. Med students often do the most thorough H&Ps (and often progress notes) and may include "little" things that residents and attendings do not. However, if anyone -- including the med student -- writes down a potential problem in the chart, it then has to be worked up and followed up on, or else the hospital risks legal consequences, particularly if there is a bad outcome. Perhaps your hospital, resident, or department has been burned by this before, which could explain why they are extra careful about student contributions in charts.

I've noticed it's service-specific at some hospitals (i.e. students did not write notes on pediatric surgery at the children's hospital I was at.) We do write notes at this hospital, and on this service. It's just a few residents don't want students writing about the patients they are responsible for.

As far as any significant physical findings are concerned, the way I was taught was that if you have an abnormal finding, you let a resident know and if they concur, great, if not, it goes bye-bye.

And these aren't extensice medicine-style H and P's either. This is surgery, where you scribble in a little bit about whatever part of the anatomy is relevant to your service.

And tothe first replie in this thread: I would have probably made the same pithy remark if someone else had been the OP 😉

 

[lvspro]

Spoke to two more attendings about this topic today. Both said that a student note is only legal if it has been signed. However, if you mention something, say a G1 sytolic murmur, and an attending signs off on it then dictates that no murmur was heard... pt leaves... comes back 2 weeks later with a completely destroyed valve then he's in deep doo-doo. The signature indicates that he has checked your work, and agrees.
Lets look at this from the other side. An attending cardiologist hears a mumur, but the student doesn't, and both document as such. >>$$ is spent working it up, and it turns out to be nothing. Assume said pt had no insurance, and decides "all that $$ and didn't find anything!! I aint payin.'" He takes the case to court, and in the chart is an MS3 note indicating no murmur. Could they legally use the fact that the student indicated absence of a murmur as legal fodder?
I know the above situation is way off the wall in terms of how to work up a murmur, but thats not the point. The point is try to look at the reverse situation, and if it holds. If it does, then maybe an MS3 note is legal.

btw, just b/c something is mentioned in court, doesn't mean you can use it, or base a case on it.

 

[CallawayDoc]

we recently went through this on surgery. all of a sudden, three days before jcaho, we were told that on surgery rotation, students were no longer to write notes in the chart. the story from the director/chairman was that residents were not reading/signing notes and it was kind of a punishment for them and to make them have to do the work.

but i think we all believe that the real reason was so attendings/residents didn't have to answer for the bs we write in charts when they had to endure the jcaho inquisition.

the chairman also got the idea to have us still write notes on cards and turn them in every day. he wants the next rotation to have 150 progress notes and 7 or so consults and h&p's on file signed and reviewed by residents so that they can use them to help determine grades and such.

 

[Doc Ivy]

The reason given is litigation, and I think it is legitimate. Med students often do the most thorough H&Ps (and often progress notes) and may include "little" things that residents and attendings do not. However, if anyone -- including the med student -- writes down a potential problem in the chart, it then has to be worked up and followed up on, or else the hospital risks legal consequences, particularly if there is a bad outcome. Perhaps your hospital, resident, or department has been burned by this before, which could explain why they are extra careful about student contributions in charts.

I think this is right on the money. It's not that M3 notes count per se legally, because everyone knows that we can't write orders or execute anything in our plan without someone to co-sign. The "problem" is that if something's not in the chart, then at litigation time no one can prove the team knew about a potential issue and ignored it. But if an M3 picked up a subtle finding that no one else bothered to document or follow up on, and something adverse happens, then it becomes easier to argue the negligence part of malpractice.

 

[Hoo\/er]

Maybe if you hadn't screwed up this wouldn't have happened.

How else are people gonna learn? 😵

 

[IlianaSedai]

Has anyone else dealt with this? The residents on my service have forbidden us to write progress notes on their patients. Apparently this is due to us writing erroneous findings and A/P's and opening the door for litigation.

But the residents have to read and sign off on all MSIII notes. It seems to me to be a simple "agree with above" followed by additional findings/reccomendations (if any) and removing anything that is wrong. Oh, and shouldn't we get practice writing these and doing the whole "clinical reasoning" thing? I mean, I'm pretty sure I'm not going to be able to suddenly write a good SOAP note on my first day of residency.

But that's just me.

Ask, "May I write practice notes that I'd throw away afterward, and ask you to review them and give me feedback? This would be really helpful to me since I need to practice note writing." 😉

 

[carrigallen]

In my limited experience, many attendings will read the med student notes because they are more inclusive and legible. Also, the notes are supposed to be double-checked by the residents and/or attendings to prevent any med student mistakes. In principle, this should reduce any possibility for litigations, etc.

I think this might be attending-specific too. I've also read notes faxed from UPenn, and the MS-3 also write progress notes.

 

[tx oms]

Has anyone else dealt with this? The residents on my service have forbidden us to write progress notes on their patients. Apparently this is due to us writing erroneous findings and A/P's and opening the door for litigation.

But the residents have to read and sign off on all MSIII notes. It seems to me to be a simple "agree with above" followed by additional findings/reccomendations (if any) and removing anything that is wrong. Oh, and shouldn't we get practice writing these and doing the whole "clinical reasoning" thing? I mean, I'm pretty sure I'm not going to be able to suddenly write a good SOAP note on my first day of residency.

But that's just me.

Shut up. Writing notes is not big deal. Be happy you don't have to write more.

 

[tupac_don]

typical response from someone who has already forgotten that they were a 3rd year a few years ago and completely clueless and had to learn at some point. or wait...maybe nicedream came out of the womb writing perfect SOAP notes. it gets so incredibly tiring to have idiot residents tell medical students that "if you hadn't screwed up this wouldn't have happened". just a few years ago you were that student that screwed up. try being a little helpful instead of an idiot.

Maybe he was maybe he wasn't. Some students are better than others.

 

[double elle]

I had this issue as well on IM...I would write "consider" blah blah blah. I was told by one attending that if I write something in the "plan" section, they were obligated to either do it, or address why it they didn't follow that recommendation. So, unless it was something I KNEW should go on the plan (their labs came back showing hypokalemia and they needed a flash or something), I would put a post-it on the note with my recommendations that I thought the patient may need. That way, my thoughts were at least writtend down for either the attending or resident to see...and they could tell me if I was right or wrong. And, more importantly, if I was wrong....I could find out WHY I was wrong. The only reason I did the post-it instead of just writing it on my notes and recommending it later verbally is that sometimes I'm off doing something else (admit, whatever) when they officially round on the patient. I like to know where my thinking goes faulty, so I put it on the post-it so the attending/resident has to tell me "yes, this is a good idea" or "no, we can't do this because....." I learned a lot that way.

 

[tx oms]

I had this issue as well on IM...I would write "consider" blah blah blah. I was told by one attending that if I write something in the "plan" section, they were obligated to either do it, or address why it they didn't follow that recommendation.

Some residents/attendings are terrible about this. In my experience Ob/Gyn is the worst. Of course, they're the worst in general... Anyway, your attending is wrong. If there were a court case in which your note came up, the defense attorney would just have to point out you're a freaking STUDENT with no experience and your attending is a physician with tons of experience; therefore, your note means nothing. Even if your note happened to be correct in hind sight, it could still easily be dealt with in court. Your attending sounds stupid and unsure of himself if he's worried a student will out do him.

 

[G'ville Nole]

To the OP,

Acknowledging that there may hospital-specific policies to the contrary, if this is the only resident group in your hospital forbidding you to write notes, it's likely to be a relatively poorly trained group of residents. On the first day of intern orientation, we were instructed on the medicolegally acceptable way to addend MS notes, something to the effect of "Patient seen and examined, agree w/ MS3 documentation with the following revisions..." and documenting elements of the note which varied from the MS note.

I personally loved having med students write notes on my patients; it condensed my own note to roughly surgical length, and saved about seven minutes per note during pre-rounds, which was enough time to go down and tank up on coffee if you knew which elevator to take!

 

[double elle]

Some residents/attendings are terrible about this. In my experience Ob/Gyn is the worst. Of course, they're the worst in general... Anyway, your attending is wrong. If there were a court case in which your note came up, the defense attorney would just have to point out you're a freaking STUDENT with no experience and your attending is a physician with tons of experience; therefore, your note means nothing. Even if your note happened to be correct in hind sight, it could still easily be dealt with in court. Your attending sounds stupid and unsure of himself if he's worried a student will out do him.

1. You sure do jump to some crazy generalizations and conclusions

2. Actually, our names aren't even on the note. We do it, they check it...and their names are the only ones that go on the notes. It's the only rotation/attending that I've had be this way, but the entire office is like that. They do all our inpatient IM stuff, and all 5 of them...the same thing. They said it has something to do with billing. Anyway

 

[edmadison]

Just some commentray from an attorney's perspective.

Anything, yes anything, written in the chart is admissible in court. In fact, anything you say is admissible. It does not matter whether or not it was cosigned. It is up to the judge/jury to attach the appropriate weight to each piece of evidence. However, if the Med Stud does pick up something and it is ignored by the resident/attending and that finding was a harbinger of something to come, it certainly would be relevant at trial. On the other hand, if there is no student note, then there is no evidence of the finding (if a tree falls in the woods....). The stupid thing about this is that all of this is just a cost of doing business. Med Studs pay to get to Med school. Academic faculty generally have a nicer life style than their private practice counter parts. So the institution/docs need to suck it up and actually teach the medical students, review their notes and discuss the findings.

ED

 

[21JumpStreet]

Shut up. Writing notes is not big deal. Be happy you don't have to write more.

I think the point here is to learn from being able to do them.

 

[RuralMedicine]

Actually, our names aren't even on the note. We do it, they check it...and their names are the only ones that go on the notes. It's the only rotation/attending that I've had be this way, but the entire office is like that. They do all our inpatient IM stuff, and all 5 of them...the same thing. They said it has something to do with billing. Anyway

This makes me a little wary about medicare/ medicaid fraud. Federal guidelines stipulate that attendings can bill off resident/intern documentation but only very minimally with medical student documentation--I think you can extract the chief complaint, social hx, and review of systems from a student H&P everything else you (or the housestaff) must document independently to be able to bill for the service. This applies to sub-Is, and housestaff signing a student note does not make it their own. It sounds to me like your institution is passing off student notes as if they were written by attendings which is unethical in my opinion.

 

[double elle]

This makes me a little wary about medicare/ medicaid fraud. Federal guidelines stipulate that attendings can bill off resident/intern documentation but only very minimally with medical student documentation--I think you can extract the chief complaint, social hx, and review of systems from a student H&P everything else you (or the housestaff) must document independently to be able to bill for the service. This applies to sub-Is, and housestaff signing a student note does not make it their own. It sounds to me like your institution is passing off student notes as if they were written by attendings which is unethical in my opinion.

I would agree if they didn't go over our notes with a fine-toothed-comb. Literally, they cross things out, add things, ect. I guess the only thing they don't do is double-check the values for everything. (It's a pre-made form...so we circle stuff for every body system for PE and there's room to write stuff in as well). I will write in the antibiotics, how long on them, the lines - when inserted and last time changed, I/O, labs - and how they've changed from the previous values, DVT/GI prophylaxis, etc...But, for the actual exam and plan....They do EVERYTHING themselves after we do. I'm not completely up on all the billing-legal stuff....but it's not uncommon for these docs to simply throw our notes away if there's too much stuff they don't agree with (luckily this doesn't happen to me too often any more!).