Hi everyone:
Most of you spend countless hours writing progress notes, so you should use this time well.
We write progress notes for two main reasons: to track a patient’s course and to communicate. Patients are complicated, and for consultants and cross-covering physicians, clear, concise notes are priceless.
Sadly, many notes are a mess of unfiltered, outdated, and irrelevant factoids. Let’s do better. Here are some precepts:
- Copying and pasting: As I wrote last week, copying and pasting can crater your credibility. If you do copy and paste, ensure your notes are accurate and up to date.
- Hospital summaries: Brief summaries at the top of the note can be helpful, but please synthesize. If Ms. Johnson was admitted three days ago with chills, fever, productive cough, and a right upper lobe infiltrate, just say she was admitted with pneumonia.
- Focused physical exams: I’m skeptical that anyone is doing head-to-toe physicals on every patient every day, though some notes imply this. After admission, focus your exams. You don’t need to check pupillary responses every morning in patients with cellulitis (assuming they’re awake and talking), but you should update your skin exam, comparing your findings to the previous day (pictures are a bonus).
- Targeted data: Don’t clog your note with reams of test results, especially radiology studies. Any reader can look them up, and no one relies on your notes to find the results of old head CTs. Show new tests and delete the rest.
- Assessments: Don’t use assessments to reiterate raw data. Show your thinking. Tell readers if the patient is making progress or not (that’s why it’s called a “progress note”). For example: “Mr. Jones is a middle-aged man with a history of IV drug use, being treated with oxacillin for mitral valve endocarditis due to MSSA, now afebrile with negative blood cultures.” Or, if the diagnosis is uncertain, you might say “Mr. Jones has ongoing fevers despite antibiotics. Given that all cultures and imaging to date are negative, we’ve begun to suspect a non-infectious cause of fever.”
- Bulleted plans: Show plans clearly. Omit random observations (“s/p 14 days of Zosyn”). Create succinct, bulleted lists, using verbs:
- Check CXR
- Follow up blood cultures
- Consult ID
- Start piperacillin-tazobactam, pending cultures
- Everything in its place: Whether you use problem-based lists (on the floor) or system-based lists (in the ICU), organize your assessments and plans. For patients with diabetic foot ulcers, separate ulcer management (wound care) from diabetes treatment (insulin). For patients intubated with multilobar pneumonia, discuss ventilator management under “respiratory” and antibiotics under “ID.”
- Be concise: Be brief. If your notes are too long, important information will get lost. Be thorough, but as with so much in medicine, less is more.
Writing effective progress notes will distinguish you as an internist. Good notes minimize the risk of dropped handoffs, they help consultants know what’s being asked of them, and they’re essential during emergencies. As a bonus, well-crafted notes save time, both for readers and for you.
Enjoy your Sunday, everyone. We flew in from Europe last night, and I look forward to seeing you again soon. Today, I’m driving down to New Jersey to visit my mom.
Mark
PS Pictures from Italy and Slovenia: