The Details that Matter Most

January 28, 2018
by Mark David Siegel

Hi everyone, A couple of attendings recently complained to me that our notes and presentations have become too long.  They’re right.  We spend too much time scrolling endlessly through computer screens and enduring meandering narratives.  Time is wasted, crucial information is obscured, and attention wanders.

A misunderstanding of the “Yale Way” template may contribute to these habits.  Long notes and presentations aren’t the point.  Rather, the intent is to outline a standard structure that fosters trenchant Chief Concerns, vivid HPIs, and lucid assessments.  The goal is effective communication, and effective communication is concise.

Don’t confuse meaningless detail with meaning.  The point is not to leave out important information, but we need to highlight what matters. So please consider the following:

  1. In your HPIs, emphasize the pertinent and delete the irrelevant. The patient’s five episodes of explosive bloody diarrhea matter.  The discussion with his wife about going to the ER?  Not so much.
  2. Say or write “non-contributory” when appropriate.*  For example, a 91-year-old woman’s family history is almost always “non-contributory.” If a team member really needs to know, they can ask- but hopefully they won’t.
  3. When you present, and assuming the team agrees, just describe the pertinent positives and negatives.  If a woman with pneumonia had a normal neurological exam, just say “her neurological exam was normal.” If someone asks about her strength, sensation, and reflexes, you can tell them.  Similarly, don’t recite strings of normal chemistries unless they’re relevant.  One exception may be in the ICU, where so many findings are abnormal that it’s often more efficient to give the whole panel.
  4. When you summarize, don’t recapitulate the details.  Synthesize and emphasize.  For example, an 81-year-old man with a DES in the LAD, on ASA and clopidogrel, and an LVEF of 15%, who is presenting with fever, cough, and a right upper lobe infiltrate is “an elderly man with heart disease, admitted with pneumonia.” 
  5. Focus on the important details.  Medication doses only matter if they pertain to the admitting problem.  For example, if you admitted a patient with hypoglycemia, give the insulin doses, but unless he’s having a gout flare, spare us the allopurinol dose. Particularly insidious is the tendency to share too much detail from the ED, like normal vital signs, exam findings and labs.  Just describe the key findings (the BP of 85/43, the RA SpO2 of 78%), test results (the LLL infiltrate), interventions (fluids, antibiotics, and oxygen), and disposition (stabilization and admission to Fitkin).

You can undoubtedly name more examples.  If you think you’re spending too much time writing notes, you probably are.  If rounds are taking too long, you may be saying too much.  By getting to the point efficiently, we’ll communicate more effectively and create more time to focus on the details that matter most. 

Enjoy your Sunday, everyone,

Mark 

PS A great book on “How to Write Short.”

M

*For billing purposes, avoid the term "non-contributory" in your notes because CMS interprets this statement as potentially indicating that a part of the history was not obtained. In turn, this would require billing at a lower level than would otherwise be appropriate. Thus when you obtain a family history (as you should), you should document your work in the chart along with a quick statement relevant to the current illness. For example, if the 91-year-old woman cited above is being admitted to rule out MI, you should include this in your H&P: “The family history was reviewed and was negative for heart disease.” On rounds, you can say “The family history was non-contributory” or not say anything at all if you deem the information irrelevant. 

Submitted by Mark David Siegel on January 28, 2018