Notes on Notes on Notes
Notes on Notes on Notes
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What's a good one-liner? Demographic + Timing + Syndrome
What's a good one-liner? Demographic + Timing + Syndrome
Avoid Reporting as much as possible. Instead, use keywords to promote Interpretation and Management.
Avoid Reporting as much as possible. Instead, use keywords to promote Interpretation and Management.
Worsening
Improving
Stable
Unstable
Uncertain
Symptom or Sign?
Symptom or Sign?
What's the reasonable differential diagnosis?
Is this part of a pattern?
Does it fit with med hx or other problems?
Dx?
Dx?
Question it light-heartedly.
Why do you agree or disagree?
Is it following expected course?
What is the trajectory?
Ongoing Inpatient Care & Discharge Plan?
Ongoing Inpatient Care & Discharge Plan?
What is the expected outpt follow-up?
What is chronic care for these conditions?
Influence of SDOH?
What could disrupt the care plan?
What services are required?
Invest the time Monday morning to get notes right for the coming week.
Remove as much data as possible, and build your note from Assessments.
BE AN ERASER, or at least a separator (for resolved problems).
Avoid daily lab values - you’ll forget to update it, it takes time to update it, they live elsewhere in the chart. Instead, comment on your ASSESSMENT, not the specific values (normalized/improving/downtrending, etc).
If you inherit a note and skim the assessment, please realize everyone else is skimming the assessment too. DELETE IT. Make your notes concise and easy to read.
Organize your problist lsit by priority:
ACTIVE, NEEDS ATTENTION, RESOLVED/STABLE.
Edit as you prechart so you can sign ASAP.
Remember it’s a PROGRESS note meaning in progress. No need update continually! It’s a snapshot in time from the morning.
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