how to write a cohesive patient note/presentation
Everyone teaches you a different mnemonic to collect information–to do a proper and thorough history and physical.
But I find few places give a concrete way to put it together and present it. You’re always told to tell a story, but then you’re supposed to just figure out what that entails. Or maybe I just missed the boat that day. Or maybe I had an attending in the distant past who just yelled at me when I was out of order but never went through the process with me.
But I think I’ve finally developed a systemic way of constructing the story for myself.
1-5 constitute the prologue:
1. Patient name, age, race, gender identity.
2. Past medical history. If it’s extensive, say so and keep it relatively pertinent to their complaint. You can list the full history elsewhere.
3. “Presents to ___” As in, did they come to the ED or were they directly admitted to a specialist service? Or is this in the clinic?
4. “via ___” Did they come by ambulance? Brought themselves/by family? Referred from clinic?
5. “c/o ___” Their main complaints at the time they came in. Any symptoms that they had on the periphery or that have come and gone can be noted by saying “a/w ___”
6-9 tell the whole story.
6. BEFORE Now that we know why they’re here, you can back up and go into their lead-up history. This will depend entirely on each patient and the nature of their complaint and unfortunately will take time and knowledge to know what is and is not pertinent. I had a patient who came in with an infection near their new lower extremity vein graft, so I talked of the previous surgeries/subsequent complications they had involving that leg. They also had a benign tumor removed from their face, but I left that out because it was unlikely to be connected (saved for the separate PSHx). The short of it is that you need the recent chronology of how they got to this point, with my interns here reminding me that while both are important, chronology > detail.
7. DURING Now you can cover the admission and move forward. “At time of presentation, patient c/o [symptoms, ROS], vital signs [stable/notable for ___], physical exam notable for ___ [if applicable], admission labs notable for ___.” When I say notable, keep it pertinent and relative to your service. Running through every single lab finding normal or abnormal is a chore for you to list and a chore to listen to. Keep it to abnormal findings and normal findings relevant to your service (WBC always worth noting when you’re on ID). And it’s better to make a judgement on a lab than not… it’s better to say “hyponatremic at 122″ instead of “sodium of 122.”Â
8. Then talk about what interventions/investigations they did. Meds, fluids, procedures, etc. Your level of detail is service-specific. On ID you can just mention IV fluids, but you need to mention specific antibiotics and cultures. Rads reports are good too (another place where you should just keep it pertinent–don’t list every single finding on a CXR. if it’s normal, or unchanged from previous chronic disease, just say “no acute processes”).
9. AFTER Kinda falls into the “during” section, but especially important to remember if you’re on a consult service and just now seeing a patient who has been here for a while: cover the interval history in brief… so everything noteworthy from admission to now, again detailed chronologically.
You might call 10 your epilogue, but you’re not necessarily ending the story so much as proposing your next chapter.
10. In terms of presentation, that’s the important stuff. Whether or not you need to present your assessment and plan at the same time or later or at all depends entirely on your attending. If you have time, obviously you get some points for having put some research into solving your patient’s ails. But as much as we pour into learning about interventions/diagnostics/pathophys, you’re going to get dinged if you can’t present/write a good note.
10a. In your plan, you are often asked to give a one-line summary. Use the backbone of 1-5, and then give a brief synopsis of what happened next. This helps the people who skip straight to your plan get a brief on your patient.
10b. When writing the plan, justify proposed diagnoses with your findings before jumping into your interventions.
This should at least give you a usable outline to keep you on track.
🙏
Wonderful! Thanks PDTN :)
