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Does anyone do this? I hate writing by hand as it is too slow. Also, it makes it easier to quickly organize your thoughts before presenting.
Using a tablet to take history/notes
- Thread starter FunnyCurrent
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I haven't seen any of my classmates do this, but that doesn't mean it isn't done. Personally, I think if you take a tablet in with you for the sole intention of taking your history/recording physical exam findings, then it's going to take you much longer than it should. When I started on the wards, I brought in a paper template with me to keep me focused. It made it easy to quickly take down a history and record my physical exam findings. Later on, I would just go in with a blank sheet of paper and jot down a few pertinent positives/negatives, and I would just flat out remember other things (e.g. physical exam findings). When I left the room, I would go an immediately type my note in the EMR. If your hospital has EMRs that you will write notes in, it would probably seem silly for you to type all that in your tablet, leave the room, and then type it all in the EMR.
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We definitely have an EMR. Would you suggest writing brief notes into the EMR as you speak with the patient and then polishing it after you leave the room?
Also, How would you prepare yourself for presentations? Would you make separate notes or just print out the note in the EMR so you have it if you forget something.
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I would print out the note from the EMR as reference, but I would have usually 1 sheet of paper with all of my patients on it with a super shorthand HPI, pertinent positives/negatives, and the plan. If during the presentation, the attending would ask for something that wasn't on my shorthand sheet, I would quickly look it up from the printed out note. The shorthand sheet is very nice, but when you first start, you will probably just read directly from your note until you get more of a hang of what is important and what is not so important to report.
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I did this on my psych rotation and it took at least 3x longer to do the same work. What I'm doing now is printing out h/p forms, print them out on 8 by 5 and get them bound at staples. costs like 3 bucks and fits perfectly in the coat pocket.
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Can your tablet access your hospitals EMR? I think is the only way your plan will save you time.
Yes, I would recommend making brief notes in the patient's room in the EMR and then polishing after you leave the room.
For making notes for presentations, it should evolve over time. On my very first rotation I would sit down and write out my exact presentation for each patient each morning separate from my note. After I got confident I would give presentations with just a copy of my morning SOAP note in front of me. Later in the year I would note just the important lab values and a few important details on the signout. By the end of third year (and definitely during fourth year) you should be able to present with nothing in front of you and have those details on a piece of paper just in case you forget. Not every attending will ask this of you, but some definitely will so it is a good skill to have.
Note:when I saw the sub-I on my team doing this my first rotation I thought it would be impossible for me to get to that point. Don't worry, presentations get much easier and you will get the hang of predicting what each attending will see as very important.
You presentation style is going to vary with each attending and so will their expectations of your presentations in terms of notes.
Yes, I would recommend making brief notes in the patient's room in the EMR and then polishing after you leave the room.
For making notes for presentations, it should evolve over time. On my very first rotation I would sit down and write out my exact presentation for each patient each morning separate from my note. After I got confident I would give presentations with just a copy of my morning SOAP note in front of me. Later in the year I would note just the important lab values and a few important details on the signout. By the end of third year (and definitely during fourth year) you should be able to present with nothing in front of you and have those details on a piece of paper just in case you forget. Not every attending will ask this of you, but some definitely will so it is a good skill to have.
Note:when I saw the sub-I on my team doing this my first rotation I thought it would be impossible for me to get to that point. Don't worry, presentations get much easier and you will get the hang of predicting what each attending will see as very important.
You presentation style is going to vary with each attending and so will their expectations of your presentations in terms of notes.
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Bingo - exactly what happened to me. First rotation I would transcribe a ridiculously long note with every detail and every explanation I could think of for my patient's pathology. By the time my sub-I rolled around I was able to carry 3 patients (this was an ICU), have no note written down, and present largely from memory with the labs/imaging info in front of me. It just takes time.
This is also something that you'll develop as you go through different fields because of the differing nature of those fields. On IM and Peds I learned how to be thorough and cover all my bases with fewer patients. On Surgery I learned how to carry numerous patients and be more efficient with my presentations. Eventually those two skillsets kinda get meshed.
(Except OB/Gyn... not sure I acquired anything from that rotation...)
