We had a good lecture on how to write a clinical note.

[royalporcupine]

"If you treat every situation where you don't know the answer as an opportunity to shame yourself, you're screwed. You're screwed forever."

Comments

hmm

[anonymous]

I understand and agree, but hope that it was made clear that you should also confidently admit when you don't know the answer (all good docs I know do). And the bad providers pretend they know and act on ignorance...and that's just scary.

Also, isn't EMR going to be 'writing' your notes for you :P
-Emily

"bad" notes

[anonymous]

Being a writer at heart, wanting to tell the story of each encounter, trying to capture the feelings of the patient along with the signs and symptoms, these are all sadly noble and creative and meaningful and pretty much completely inappropriate approaches to medical note writing. The very scantest list of individual characteristics without pretending for a minute that it is a narrative: age gender, race, medical conditions. Review of systems for subjective info: Headache, dizziness, chest pain, palpitations, nausea, vomiting, constipation, diarrhea, paresthesias, edema. Meds. Vitals, labs results, exam. Diagnoses. Plan: new labs, new meds, follow up.

When my notes look like this, in other words when they look the way they are supposed to look, you will know I have lost my heart.

I hope you will write good notes and save the narratives inside your head, maybe share them with willing listeners.

Good luck, Sandu.