Our notes and presentations are improving a lot, but certain bad habits still drive me crazy. So please:
- Drop irrelevant facts from your Chief Concern: Do we really need to know that your 65-year-old man with cellulitis has BPH? Diabetes, sure, but BPH? That’s just distracting.
- Don’t call men and women "males" and "females": That’s dehumanizing.
- Don’t confuse pertinent positives and negatives with the "review of systems": When your patient has pneumonia, tell us about the fever, chills, cough, sputum, chest pain, and shortness of breath. Those findings are pertinent. The review of systems screens for unrelated problems and does not belong in the HPI.
- Edit what you say about the ED course: Don’t torture us with the temperature of 98.6 and heart rate of 72. Instead, share crucial details, like the hypoxia that responded to supplemental oxygen, the CT showing a PE, and the decision to start heparin.
- Delete non-contributory history:A 99-year-old woman's family history is almost always “non-contributory.” Enough said.
- Include details that matter: If your patient’s mental status is altered, don’t just say she was disoriented. You also need to describe her level of consciousness, affect, short term memory, and ability to spell and calculate.
- Withhold follow up lab tests until you describe the hospital course: It makes no sense to describe the resolution of hyperglycemia before saying you gave the patient insulin. Just share the results that informed your initial assessment and plan. After that, when you describe the subsequent hospital course, the follow up tests will make sense.
- Don’t call lab results "objective data": Aren't your history and exam findings objective too?
- Don’t conflate summaries and assessments: Summaries highlight the salient facts. Assessments tell us what you think it all means.
- Don’t ever copy and paste old information:This mistake is dangerous. Irrelevant information makes notes too long and buries the important stuff. People stop reading notes because it’s not worth the effort and communication suffers. Leave out old lab and imaging results and expunge endless soliloquies on established facts- we don’t need to hear about the epigastric pain, hematemesis, melena, and hemoglobin drop once the endoscopy is done and we know the patient has an ulcer. And most importantly, make sure everything you sign off on is up to date and accurate. If you copy forward “full code” after your patient is made DNR, what’s going to happen when her heart stops?
The common wisdom among medical educators is that residents don’t care anymore about high quality notes and presentations. Let’s prove them wrong. Let's stop driving each other crazy and raise our work to the next level.
Happy Sunday everyone,