Think Before you Sign

August 04, 2019
by Mark David Siegel

Hi everyone, 

Back in the Pleistocene, when I was an intern, we wrote progress notes on paper. With pens. To ward off writer’s cramp, we kept the notes short. Sometimes, just a few lines:


To save time, we used abbreviations and acronyms. “IPN” was “Intern Progress Note.” “VSS” was “Vital Signs Stable.” The “c” with the line above it was an abbreviation for the Latin “cum” or “with.” The triangle (or delta) stood for change. We used the “SOAP” format (subjective, objective, assessment, and plan). Medical students often wrote out “S:” “O:” “A:” “P:,” but we were too cool for that. Still, everything had its place. 

For more complicated patients, we wrote comprehensive notes, but only when necessary. We’d never waste time rehashing old information. We referred readers to prior notes. 

In the days of pen and paper, we recognized each other’s handwritings. Some of the most brilliant attendings wrote notes that were completely indecipherable, so we ignored them. We had no time to figure them out and we were too intimidated to ask the attendings what they wrote. This was a shame, of course, especially for the patients. We read notes that were legible. Otherwise, we moved on. 

Fast forward to today and everyone’s notes are legible, but that doesn’t make them readable. With the ease of copying and pasting, too many notes have morphed into bloated repositories of old news, random facts, and ponderous narratives. We’ve evolved from pen to keyboard, but the shame is the same: We still read selectively, and brilliant physicians write notes that no one reads.

It’s not that hard to write concise, accurate notes. Here are some suggestions: 

  • Follow the SOAP format (but don’t write “S,” “O,” “A,” and “P”). Put information in the right place and guide readers to the information they need. 
  • Delete old data. You can highlight new, important test results, but delete them the next day. People can’t find new information buried in the old. They just scroll through this section anyway. 
  • Update your impressions. On the first day, you can explain why your patient with fever, headache, and stiff neck probably has meningitis. The next day, when the LP is back, just say she has meningitis. The next day, when you know the culture results, call it pneumococcal meningitis. Reiterating the presenting symptoms just clutters your note. 
  • Create pristine assessments and plans. Here’s a fictional bad example (don’t worry, it’s not you): 

             #STEMI: Presenting with four hours of chest pain radiating down the left arm, Troponin 6.2, EKG with 5 mm ST-segment elevations in V1-V4    

                  -Start ticagrelor, ASA, heparin, high dose statin    

                  -Monitor on Telemetry    

                  -Cardiology thinks she may need PCI    

                  -S/P CABG 10 years ago    

                  -Echo with anterior wall motion abnormalities 

I hope you share my concerns. Information is scattered, the assessment just repeats the history, and raw data are listed without interpretation. Also, cardiology’s opinion isn’t your plan. Here’s a better example:  

              #STEMI: supported by the patient’s classic history, high troponins, anterior ST segment elevations on EKG, and new wall motion abnormalities on echo. She needs immediate treatment.    

                    -Begin ticagrelor, ASA, heparin, and high dose statin    

                    -Monitor on telemetry    

                    -PCI ASAP (discussed with cardiology)

  • Use copying and pasting selectively. In my Utopian hospital, no one would copy and paste. Using EPIC’s “Hide Copied Text” button, I’ve found notes that are at least 95% replicas of prior entries. If you do copy and paste, watch out for these no-noes:
    • Don’t copy forward physical exams. Anyone reading these exams will conclude, often correctly, that you didn’t actually examine the patient that day. Does anyone really believe you’ve done a full head to toe exam on every patient every day, even when nothing is changing and all the words are the same? A targeted exam, highlighting new findings, is much more appropriate.
    • Never copy content from other clinicians without providing attribution. That’s plagiarism.
    • Don’t copy and paste old information. Old information rapidly morphs into nonsense. Nothing drives me crazier than reading about plans to extubate patients who were extubated the day before.

It’s often said that we waste too much time on the computer, but I see the problem differently. We waste too much time on the computer wasting time. Today as always, we can add value to the record by writing excellent notes that memorialize the patient’s story and convey our thoughts. Concise, meaningful notes save time for both writers and readers. So let’s commit ourselves to mastering this crucial skill. Let’s make progress with our progress notes, and please, think before you sign. 

Enjoy the rest of your weekend, everyone, 

Mark

Submitted by Mark David Siegel on August 04, 2019