How to write better H&Ps and notes?

[Pisiform]

I am a 4th year MS matched into IM. I am not really great at writing notes. My notes usually don't have the 'medicine language' and sophistication that some of the residents have. I have seen some great notes that flow nicely and don't have information scattered around and only use words which makes you think it is written by a pro.

My notes kinda sound like lay mans language to me and not that good even though I include all the medicine stuff.

Does anyone have any advice or books I could read to make my notes sound better ?

Thanks


Sent from my iPhone using SDN mobile

---

Members don't see this ad.

 

[drfunktacular]

Same way you get to Carnegie Hall: practice, practice, practice

I would also solicit and take seriously advice from your intern/resident/attending about your notes. They will probably give you tough feedback, but that is how you learn

 

[tantacles]

I am a 4th year MS matched into IM. I am not really great at writing notes. My notes usually don't have the 'medicine language' and sophistication that some of the residents have. I have seen some great notes that flow nicely and don't have information scattered around and only use words which makes you think it is written by a pro.

My notes kinda sound like lay mans language to me and not that good even though I include all the medicine stuff.

Does anyone have any advice or books I could read to make my notes sound better ?

Thanks


Sent from my iPhone using SDN mobile

Big thing for assessments: lead with your diagnosis, and then present your evidence for that diagnosis after. Too many medical students repeat their physical exam and lab results in the assessment without having the context of a diagnosis (or multiple diagnoses if you have an undifferentiated problem) to support their inclusion.


Large dogs

 

[gutonc]

Also...don't forget to rule things out in your assessment with supporting data from labs/imaging/exam. If they're short of breath and your exam/labs/echo don't support CHF exacerbation, get that out of everyone's head quickly so you can all focus on what might be causing it.

 

[Psai]

Write your notes then compare it to what your attendings and what the specialists say. You will get better as you learn the pathophysiology. It's a gradual process, even Newton wasn't writing Principia on day one.

 

[doctorbeastmode]

Less is more.


Sent from my iPhone using SDN mobile

 

[cbrons]

A: CHF

P: See orders

Sent from my SM-N910P using SDN mobile

 

[DoctwoB]

Less is more when it comes to auto-populated info. All that stuff does is hide the important information, notably your subjective and plan. As a consultant who frequently reads medicine notes, the ones I find most helpful are light on E-record autopopulated info (meds, vitals, labs, imaging reports, etc.), as it is easier for me just to look at that myself, and focus on explaining the plan and rationale for it. Unfortunately I too often see the opposite, which is an H&P of 5 pages of worthless e-record gibberish followed by 1 line of plan.

 

[Crayola227]

ditto that a lot of writing is learned by reading and apeing

monkey read monkey write

 

[mdjo]

On some of our rotations, a med student writes the note and then sends it over to me to sign under my name and count as the full H&P or progress note. Any time I am signing (not co-signing) one of their notes under my own name, I have the student pull up a chair and we edit the note together for clarity and accuracy. It helps me understand where they're at as far as medical knowledge and understanding the case, and it definitely helps them write more doctor-y notes and understand the assessment and plan for each patient better (which then makes their presentations much, much better). Ask your residents to do the same for you!

 

[rokshana]

On some of our rotations, a med student writes the note and then sends it over to me to sign under my name and count as the full H&P or progress note. Any time I am signing (not co-signing) one of their notes under my own name, I have the student pull up a chair and we edit the note together for clarity and accuracy. It helps me understand where they're at as far as medical knowledge and understanding the case, and it definitely helps them write more doctor-y notes and understand the assessment and plan for each patient better (which then makes their presentations much, much better). Ask your residents to do the same for you!

though a med student's note isn't a billable note so not sure how you can do this unless you just copy and paste their note in your account...but doesn't that look a but suspicious if your note and the med students are identical?

 

[Raryn]

though a med student's note isn't a billable note so not sure how you can do this unless you just copy and paste their note in your account...but doesn't that look a but suspicious if your note and the med students are identical?

Some EMRs allow the medical student to write a note acting as a scribe for a resident/attending. That is, they can open a note under their own name and write a plain old med student note (which can't be billed off of)... or they can start a note under a physicians name, write the whole thing, but not have the ability to put a final signature on it.

Where I'm at it's enabled, so I have my med students start their notes with me listed as the author, they write it as best they can, then I sit down with them, edit it to the form I like, and sign it. Their name is in a field buried in the EMR as acting as my scribe but the note is filed under me. Our attendings do the same thing with them in clinic.

 

[CatFactorial]

Free text your notes; no templates. No auto populating labs; only include the ones of relevance (people can easily check the full labs tab if they need clarification). When possible, include your own personal reads of X-rays, ekgs (can comment something like "per personal/R1 read"). Regarding vitals, my med students frequently comment on the O2 sat without including what FIO2. When doing your assessment and plan, do not repeat the HPI, brevity is key (although as mentioned above explaining your reasoning for your differential is important). Be sure you are updating the assessment with each day. It is poor form to keep referring to a patient with type I NSTEMI s/p PCI as an "ACS rule out."

http://www.nejm.org/doi/full/10.1056/NEJMra054782

Excellent paper on problem representation and clinical reasoning.

 

[Siggy]

When doing your assessment and plan, do not repeat the HPI, brevity is key (although as mentioned above explaining your reasoning for your differential is important).

THANK YOU!

I never got the need a lot of people have for starting their A/P with

"XX year old XX with history of X presented for X

Problem 1
Problem 2
Problem 3"

 

[wjs010]

I start each Progress note with a small summary of their current reason for coming and major things during their stay so far( almost like a discharge summary) then in a separate paragraph write about that days stuff. Is this good or should I notworry about the first part? Thanks. Also do you write out macrocytosis as an assessment for example if Mcv is high or do you only include it in labs. I've seen people do that and it just seemed slightly pointless... that's more of a lab, not a dx. I just want to include the main major ddx


Sent from my iPhone using SDN mobile

 

[rokshana]

I start each Progress note with a small summary of their current reason for coming and major things during their stay so far( almost like a discharge summary) then in a separate paragraph write about that days stuff. Is this good or should I notworry about the first part? Thanks. Also do you write out macrocytosis as an assessment for example if Mcv is high or do you only include it in labs. I've seen people do that and it just seemed slightly pointless... that's more of a lab, not a dx. I just want to include the main major ddx


Sent from my iPhone using SDN mobile

the summary is a good idea...helps those that are reading it (unless its pages long) and will help you (or the resident after you ) with the D/C summary.

 

[Psai]

I start each Progress note with a small summary of their current reason for coming and major things during their stay so far( almost like a discharge summary) then in a separate paragraph write about that days stuff. Is this good or should I notworry about the first part? Thanks. Also do you write out macrocytosis as an assessment for example if Mcv is high or do you only include it in labs. I've seen people do that and it just seemed slightly pointless... that's more of a lab, not a dx. I just want to include the main major ddx


Sent from my iPhone using SDN mobile

People do it for the billing. If you don't do it, you're leaving money on the table.

 

[CopaceticOne]

People do it for the billing. If you don't do it, you're leaving money on the table.

Exactly. It is the reason I try to always write encephalopathy vs altered mental status in my problem list / A&P. The high school level coders seem to only bill for the former.

 

[Raryn]

People do it for the billing. If you don't do it, you're leaving money on the table.

Acute on Chronic Systolic and Diastolic Decompensated Heart Failure

 

[wjs010]

People do it for the billing. If you don't do it, you're leaving money on the table.

Well then I won't miss that ever again


Sent from my iPhone using SDN mobile

 

[CatFactorial]

Acute on Chronic Systolic and Diastolic Decompensated Heart Failure

If I had to count all the billing emails asking for clarification about CHFrEF... it'd be three.


But still annoying.

 

[FlowRate]

THANK YOU!

I never got the need a lot of people have for starting their A/P with

"XX year old XX with history of X presented for X

Problem 1
Problem 2
Problem 3"

They said "don't repeat the HPI" not "don't have a one-liner."

The reason you include a one-liner in the assessment is because that's where it'll live in all your progress notes and sometimes it's the only thing people actually read.

 

[Raryn]

If I had to count all the billing emails asking for clarification about CHFrEF... it'd be three.


But still annoying.

That one was annoying, but the worst was our VA would obsess over "AKI", 100% of the time emailing to ask if it was "acute kidney injury" or "acute kidney insufficiency".

I would just pick one at random when asked to clarify. Not like the VA billing actually matters, it's monopoly money anyway.

 

[nlax30]

In reply to the OP, I think the current environment has done a disservice to medical students in regards to H&P's at some places. With the current regulations of documentation and billing it seems like the med student's h&p is an afterthought and either not done or not reviewed. I remember during my 3rd and 4th year hand writing full h&ps before we got EMR that were used in the chart and fully reviewed with the resident and attending and then co-signed. With out current EMR the med student can technically type one up but it isn't used in any official capacity and sometimes just doesn't get done so I think they miss out on that practice in many cases.


Sent from my iPad using Tapatalk

 

[Psai]

That one was annoying, but the worst was our VA would obsess over "AKI", 100% of the time emailing to ask if it was "acute kidney injury" or "acute kidney insufficiency".

I would just pick one at random when asked to clarify. Not like the VA billing actually matters, it's monopoly money anyway.

Which one bills more?

 

[GadRads]

AKI on CKD. Billing: "Doc, what stage of CKD?" I always write the CKD stage to avoid to pages from the billing dept.