#Record notes for memory how to

Of the many patients IвЂ™ve seen in the past three years, these two are among the hundred cases I could present as though I just finished talking with the patient. Here are two examples from about 5,000 that I have accumulated since medical school: For me, this record of pathology and molecular mechanisms is intermingled with memories of tears and laughter. The more random the better-captured correctly, a strange component of the interaction can jog my memory of the entire encounter. On the second line, IвЂ™ll note a learning point, any procedure I performed, and one other piece of the patientвЂ™s story. The first line lists the patientвЂ™s initials, gender, date seen, and chief complaint or diagnosis. ItвЂ™s a bare-bones technique every patient I see gets two or three lines in a pocket journal. This works really well in the emergency department, where I spend most of my time. One easy-to-start technique IвЂ™ve found helpful is keeping a log of every patient I encounter. TraineesвЂ™ notes can benefit from telling patientsвЂ™ stories in places other than the medical record. Tapping into that tradition will enrich physiciansвЂ™ notes, and may even improve patient care. For millennia, humans have told stories to make sense of the world around them. A senior clinician once shared with me that, when it comes to the medical record, the best physician documentarians are great storytellers. To become an EMR wordsmith requires more than simple learned efficiency, a fact that is often neglected in medical education. This is why the attending hospitalist efficiently enters numerous notes on one call while the new intern feels swamped by 3 admissions.

Ten admission notes in one overnight call? No problem! The writing taskвЂ™s transition from labored struggle (for students) to automatic function (for senior residents) is accompanied by improved readability. SOAP only dictates an order of information, not content or style. While this general outline is necessary, following it does not guarantee that the note will be any good. The SOAP mnemonic (Subjective, Objective, Assessment, Plan) introduces students to the importance of providing information in the standard manner physicians are used to.

#Record notes for memory how to

Much has been written about how to write good medical notes. The best writing takes documentation to the next level-it reveals a doctor's compassion for the patient.

In a busy emergency department, discharge summaries and problem lists impart the most information in a quick read a physician preparing for the next dayвЂ™s office visit benefits most from reading specialistsвЂ™ recent notes. Good notes facilitate continuity of care, since many physicians gather background information in the electronic medical record (EMR) prior to meeting a new patient.

Do you remember the last time you read an excellent physician note? If it was similar to any of the gems I've discovered, it was well organized and included the pertinent data from the encounter, all the while keeping the patient at the center of the dialogue.