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In Pursuit of Excellence (Writing Notes)

July 02, 2023
by Mark David Siegel

Hi everyone:

We internists spend lots of time writing progress notes, transfer notes, event notes, H&Ps, and discharge summaries. It’s torture to read notes that are too long, repetitive, unedited, excessively detailed, and, worst of all, inaccurate. Today’s bad notes are a byproduct of the EMR. When I was a resident, I contended with lost charts and inscrutable handwriting. Nowadays, information is legible, but crucial facts lie hidden within lists, factoids, and zombie narratives that refuse to die.

Excellent notes provide the information we need to care for patients. What were the symptoms? When did they start? How severe? What made them better or worse? What did the exam and blood work show? What did the medical team think was going on and how did they respond? What followed?

Excellent notes are succinct, timely, and accurate. Teammates, consultants, and, increasingly, patients, read what we write. The following list highlights core features of excellent note writing. The list isn’t exhaustive, so fill free to add your own examples.

  1. Document your role: When you see a patient, leave a note. If you’re a resident helping an intern admit a patient, addend their H&P. If a nurse asks you to see a patient you’re cross covering, leave an event note. The saying “if it’s not documented it didn’t happen” isn’t literally true, but it might as well be true for future colleagues who can’t tell what, if anything, you did.
  2. Start with a helpful one liner: The Chief Concern (CC) frames your note, highlighting age, gender, and key background. Single words like “headache” are insufficient. A 20-year-old woman with a history of migraines presenting with her typical headache is entirely different from a 45-year-old man with poorly controlled hypertension presenting with the worst headache of his life.
  3. Respect your patients: Consider your words. We care for people, men and women—cis, trans, or non-binary—not “males” and “females.” We care for people who use drugs, not drug abusers. Patients can and do read your notes, so make sure everything you write is accurate and respectful.
  4. Filter: Don’t flood your narratives with listicles. Don’t write “the patient is a 73-year-old woman with a history of colon cancer s/p colectomy, atrial fibrillation on apixaban, obesity, OSA on CPAP, s/p hysterectomy, and asthma, presenting with left wrist pain after tripping on the sidewalk. Instead, highlight what matters: “the patient is a 73-year-old woman presenting with left wrist pain after tripping on the sidewalk.” Other details belong in the Past Medical History.
  5. Go in order: Humans understand stories, so create a sequential narrative. Start at the beginning: “Mr. Cohen was in his usual state of health until the morning of admission when he awoke with crushing sub-sternal chest pain. He took Maalox without relief. Over the next 15 minutes, he became short of breath and lightheaded, after which his husband called an ambulance, which brought him to the ER. In the ER…etc.
  6. Don’t confuse “Review of Systems” with Pertinent Positives and Negatives: The Review of Systems (ROS) is an inventory of potential concerns you should ask of all new patients. The goal is to uncover problems peripheral to the chief concern. For example, I screen all new pulmonary patients for sleep disorders, including those seeing me for cough and shortness of breath. In contrast, pertinent positives and negatives refer to the chief concern. For example, if you’re seeing a patient presenting with cough, you should note if they have fever, chills, runny nose, sinus pain, sputum, hemoptysis, chest pain, and shortness of breath.
  7. Show your thinking: Readers want to understand your clinical reasoning, so when you write assessments, you should summarize and synthesize the salient facts to create a weighted differential diagnosis. For example: “Ms. Taylor is an otherwise healthy 21-year-old woman who presented with low grade fever, headache, photophobia, and mild neck stiffness in the setting of an outbreak of meningococcus in her dorm. Labs are notable for leukocytosis with a left shift. She is almost certainly infected. Diagnostic considerations include simple viral illness, tick-borne disease (e.g., Lyme), and meningitis (both viral and bacterial). Given her potential exposure to meningococcus, early bacterial meningitis is our major concern.”
  8. Show your plans: Don’t hide your plans within factoids and observations. Too often, note writers sow confusion with comments like “hematology seeing patient” or “s/p 1 unit of PRBCs,” which, to put it bluntly, are not plans. Instead, use succinct, bulleted action statements like:
    • Discuss possible bone marrow biopsy with hematology.
    • Check post-transfusion H/H.
  1. Finish at a reasonable time: Take it from someone who’s been writing notes for 35 years: the longer you take to write your notes, the harder they are to finish. Aim to finish them by early afternoon, while you’re still fresh. Remember, consultants rely on your notes to see what you’re thinking, and attendings need to read and attest your notes well before the end of the day. For new interns, finishing notes by early afternoon may be aspirational, but this goal should be achievable by late summer or early fall.
  2. Be concise: No one wants to read long notes. It’s hard to focus as you scroll though protracted narratives, tedious lists, and old test results. Inevitably, important information gets lost. Delete outdated information and consolidate raw data into diagnoses: for example, a “warm, red, painful big toe” on Day 1 becomes “gout” once you’ve made the diagnosis.
  3. Be accurate: Do not— I repeat do not—post notes containing false information. Copying and pasting from old notes is risky at best (and copying others’ notes without attribution is plagiarism). Too often, when I unclick the “copied” button on Epic, I find fallacies that would be laughable if they weren’t so dangerous, like exams documenting rashes that have resolved, or plans to start antibiotics that have already been started. Inaccurate notes sow confusion, place patients at risk, and hurt your credibility.
  4. Proofread: Run a spellcheck, go over your plans, and review your comments one last time. After you sign, share your note with your attending so they can read your work, give you feedback, and enter an attestation. Aim to be proud.

Writing excellent notes is a process of continuous practice and refinement. Over time, your notes will become increasingly clear and concise. I continue to work on mine, and I encourage you all to work hard on yours to pursue excellence.

I’ll be heading out for a bike ride now before the rain returns. Then, I’ll sit down to tackle 32 letters of recommendation for fellowship. Our “Pursuit of Excellence” series continues next week.


P.S. Views off East Rock:

Submitted by Mark David Siegel on July 02, 2023