Do you ever get stressed out when you’re told to have your progress notes ready by a certain time? Do you ever spend more than 30 to 45 minutes doing your notes? Do you not know what to add and sometimes add too much? What’s a consistent method of writing notes in medical school anyway?
In this post, I will go over a step-by-step approach to writing notes in medical school. This will be a technique that you can use every morning to not only have your notes in but to do them well.
Develop a Structure Before You Begin Your Notes:
I’m assuming we’re referring to writing notes on our patients before rounds. If you’re in clinic then the approach is similar.
The first thing I do in the morning is to have a structured way of collecting overnight data.
I open my progress note template. The template is something I’ve precreated and seperates my note into the typical SOAP (Subjective, Objective, Assessment/Plan) format. Since I have a template I can just type in overnight events, new vitals, the physical exam that day, and the plan for the day.
First I read the notes since my last progress note. I pay attention to any major events, new symptoms, or specialist recommendations in the subjective portion of my note. Don’t worry about grammar or spelling right now. We’ll make final adjustments later.
Then I move on to the vitals. I write down the ranges for the heart rate, blood pressures, and temperatures in my note. At this time if you notice abnormal values, pay attention to the time(s) which these anomalies occurred. If your patient becomes tachycardic overnight everyone is going to want to know reasons why.
Next, I review the medications my patient has received in the last 24 hours. More importantly, focus on the dose/frequency of pain medications as well as fluids they’ve received.
Finally look at any lab results.
Use this strategic approach and to easily write notes in medical school.
Even before you see your patient you now have a 75% completed note. As the flow of information becomes second nature you can do this first draft of your note in less than 10-15 minutes.
Prefill the Questions You Need to Ask Your Patients:
Now that you’ve prefilled your note, add in the questions you need to ask your patients.
One of the best ways I know to write efficient notes is to have efficient patient interactions.You don’t need to rush in and out of your patient’s room. If anything, this leads to poor notes and presentations.Instead, use the information you gathered about your patient over the last 24 hours and think what’s important to ask and examine.
For example, if your patient has episodes of tachycardia overnight, ask about SOB, palpitations, fevers, and UOP. These questions will help you differentiate pulmonary embolus, infection, arrhythmias, and/or shock.
Now if you had instead gone to your patient’s room without a plan, you likely would have forgotten some of these questions.
You’ll look more impressive in front of your team if you beat them to the punch and start ruling diseases in/out based on your questioning.
After you’ve seen your patients, fill in the answers of your patients to your questionioning and add anything pertinent they mention.
Finalize Your Note With Your Team:
You now have an almost completed note which has taken minimal effort.
The final thing to achieve a perfect note is to draft your plan. Yes, you can just ask your resident what the plan is. That, however, is the quality of a “high pass” student.
To achieve honors (without being obnoxious) draft a plan for your patients. Do they need any new medications? Should you consider order imaging? Does their discharge plan change at all?
Consider all these questions, come up with potential solutions, and then present those ideas to your resident. You’re likely going to be wrong on something. That’s totally fine. You’re showing effort and that you care about your patient.
Once they point you towards the actual plan, add this to your note and finalize your note.
Now you understand my step-by-step approach to writing notes in medical school every morning.
I’ve been complimented by residents and attendings on my notes being concise and informative. Below I add additional tips that I use to write quicky yet high-quality notes.
Separate Out Paragraphs By Patient’s Problems:
I’ve seen many notes where the subjective is just one long paragraph. You have to work hard to just find the information you need. Once you find it, you’re hoping the quality of the information is good.
Instead, split your patient’s problems into paragraphs. For example, recently at an Ob/Gyn clinic I had a patient present with dysmenorrhea and heart palpitations. I could have written all her problems in one paragraph. No one is going to read the “book” written by the medical student.
Instead, I split her problems up. I began the first paragraph with “patient complains of (insert symptoms)”. Then I add all the related information to that problem in a chronological order of how her symptoms presented. This is the same approach I use when I’m presenting. Check out my post on presenting patients in medical school to learn more.
The second paragraph can then be, “regarding patient’s complain of (symptom B).” and add in the corresponding info.
Now your reader can look at your note and focus on one problem at a time.
If you look at your patient’s note and can’t identify a flow, then you need to restructure it. Make sure each problem is separated. With each problem include a description of symptoms and any management that has already been done.
Below I have typed a brief example of what a subjective in one of my notes may look like.
“Patient is a 38 yo female with PMH of HFrEF (EF 35% by echo 1/20/2012), T2DM (A1C 8.9% 5/17) who presents on 2/17/18 with SOB and lower extremity edema.
Overnight patient states SOB has improved. Received Lasix 40 mg x 2 yesterday and patient reports good UOP (1000 cc per chart). Patient has been able to ambulate around in the room without difficulty. Denies a productive cough, headache, dizziness, or fever.
Regarding lower extremity edema, patient states the size of her lower extremities is back to baseline. No longer complains of pain when walking.
Patient does have a new complaint of constipation this morning. Has not had a BM for two days. Still passing flatus. Has been tolerating PO and been receiving PO. ”
Boom! The note is split according to the patient’s problems and you can move from paragraph to paragraph depending on what you want to know.
Forget About Writing Perfect Notes In Medical School:
I’ve been on rotations with classmates who require hours to write their notes. Bless their hearts but they were trying to be too perfect.
News flash – a medical student’s note holds very little (if any) value.
So use the above approach to write a thoughtful and efficient note. but don’t spend a majority of your day writing your notes.
What to Watch Out For When Writing Notes in Medical School:
The biggest thing is to be consistent with the rest of your team. Don’t add a plan in your note that is the opposite of what your team is doing for the patient.
This provides confusion for anyone reading your note and doesn’t realize it’s written by a medical student. They may put weight into your plan which may not be completely correct.
This is why it’s important to confirm the plan with your resident. If you notice a discrepancy, later on, added your note.
Also remember while no one may read your note, act like it’s the only one that matters.
This means don’t put unnecessary detail and paint a solid picture of the patient’s complaint.
Sometimes I’ve used the notes of fellow students to best understand the state and care of a patient. Residents are typically brief and may forget detail which is important to mention. So be more descriptive than your resident in your notes without writing a book each day.
Now you fully understand my step-by-step approach to writing notes in medical school. You can now write your progress notes quickly and without stress.
This process is also beneficial because you’re patient interviews are much quicker and focused. You don’t go into your patient’s room asking about x y and z they don’t matter. Having a note already pre-written is going to structure your interview. Not only what your interactions with your patients be more focused they will feel like you know what you want to ask.
Once you complete your interview, it’s as simple as entering the information.
Using the above approach I’ve been complimented on the quality of my notes. Now you can do the same!
So there you have it, this was the step-by-step approach that I use every day on writing notes in medical school. Not only does this prevent me from coming into early but it prevents me from leaving too late. I hope you can use these tools to better facilitate your morning rounds and H&P’s.
If you enjoy this post check out the following posts:
How to Skillfully Present Patients in Medical School
How to Build Strong Relationships with Your Patients
Power of Fake Confidence: Overcoming the Impostor Syndrome
Regaining Motivation in Medical School
If there is something specific you’d like me to address in a future blog post, comment below or email me at [email protected]
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Until next time…