Each week, starting with the first week of the clerkship, you must give to your site coordinator or principal preceptor the visit note for a patient you treated as a major provider. These notes should be in the format specified in the prospectus [see section entitled "visit notes"]. Be sure to also give this preceptor the visit note evaluation form. You may expect to receive your annotated note and the completed evaluation form within 48 hours. Your note should be appropriately short (rarely more than two handwritten pages) but complete for the problems identified during the visit. Be sure the review of systems is complete for all problems and that you discuss a differential diagnosis. Justify your diagnosis and plans.
If the notes you write as part of routine care are complete and suitably structured, a copy will suffice for this exercise. Otherwise re-do your official note. If you choose to submit a note on a new patient (complete H&P), it should be as long and detailed as an in-patient admission note.
Guidelines for Writing Notes
You will be graded for each note on a scale of outstanding, excellent, very good, satisfactory, and poor. In your final evaluation for the clerkship, we will indicate your average grade, with missing notes graded as “poor”.
Criteria for an "outstanding" grade on any note:
- Patient's name, unit number, and visit date on each sheet
- Write Your Name Clearly
- Be willing to declare your identity and assume responsibility for your work.
- Clear writing of your name is an important courtesy to the patient and to other providers. Make it easy for other providers to locate you.
- The organization should follow SOAP guidelines. SUBJECTIVE means only what the patient tells you (i.e.: symptoms, attributions, etc.) or what you know to have occurred in the past (i.e.: a medication change you made based on a telephone conversation with the patient). Results of consults can be placed here or in the objective section. Do not indicate impressions or results of your physical exam in the subjective section. OBJECTIVE includes results of physical examination and interval test data. ASSESSMENT includes you interpretation of information in the previous two session. PLAN is what you are going to do about your impression. I usually list my plan under each individual problem's assessment, as in the example above.
- In general, do not list the past medical history. This should be clearly indicated on a master problem list. If the master list is not in the chart, make one after the visit.
- Organize the “subjective” section by problems and be sure your problems reflect 1) the patient's agenda and 2) what you identify to be the important problems that need to be addressed during the visit (i.e.: the patient may not bring up health maintenance as a problem, but you should always list it in the subjective section).
Use the same terms for problems so that a physician can quickly review the history of the problem by glancing at past visit notes.
- List medications at least every other visit or whenever there have been important interval changes. USE GENERIC NAMES, INDICATE STRENGTH OF TABLET OR CAPSULE (At our clinic, patients may obtain refills by telephone. A nurse reviews most recent visit note for information on what medications are being taken, strength of tablets, signature, etc. If you are not clear in your notes, mistakes may occur).
- Be sure the problems in the “assessment/plan” section correspond to those listed in the subjective section.
- On every note indicate specific plan for follow-up (e.g.: RTC 2 weeks to see Dr. Kernan).
- On every note, indicate name of supervising attending (e.g.: "seen with Dr. Kernan").