Transcript Teaching from Review of the Progress Note

Teaching from Review of the
Progress Note
Tayloe Loftus, MD
SUNY Syracuse
Updated 2010 by Heather Harrell, MD, FACP
University of Florida, Gainesville
Why Read a Student’s Note?
• “Scut”  Teaching!
• Identify student learning needs
• “Case-based” teaching better than
lecture
• Ensures accuracy of the medical
record
What are some of your “pet peeves” with
students’ progress notes?
• Too long
• Too detailed
• Not detailed enough
• Not accurate
• Lack plans
• On the chart too late
How have you set expectations with
students?
• Practical suggestions
– Heading
• How should they label their note?
• “Date, time, stamp, sign”
• Hospitalization context (e.g. day # of antibiotics)
– Length
• ≤ 1 page, telegraphic language (don’t need
complete sentence)
– Organization (SOAP)
– Timing (when should it be on the chart/EMR)
– Billing/compliance issues
Setting Expectations: Data Reporting
• Subjective
– Patient’s input on major problems (minor
concerns don’t need to go in the note)
• Objective
– Vital signs are vital, don’t forget them
– Report pertinent exam (problem focused,
exam changes, findings that change
management)
– Clarify how you want meds listed and how
often
Setting Expectations:
Avoiding the “SOP” Note
• Assessment/Plan- Diagnosis-based, not
systems-based
– Commit to a working diagnosis and plan for each
problem before discussing the case with you
– Prioritize problems/diagnoses
– Brief assessments reflecting the most current thinking
(not summaries of the whole hospitalization)
– Plans should include therapeutic endpoints for
discharge/care transition planning
• Addenda
– Clarify when should notes be addended
Sample Notes
• What can you learn about the student from
this note
What can you learn about a student
from the note?
• Communication skills
• Organizational skills
• Professionalism (timeliness, plagiarism)
• Physical examination skills
– Components – HEENT, lymph nodes, neuro
– Meaning – “no tactile fremitus”
– Knowledge physical manifestations of disease e.g.
omitting JVD or S3 assessment in patient with CHF
What MORE can you learn about a
student from the note?
• Clinical reasoning
– Pertinent +/-’s
– Appropriate prioritization of problems
– Accurate representation of team’s reasoning
• “Icing on the Cake” (Manager-level behavior)
– Interesting additions to care?
– Evidence of reading?
– Attention to “finer points” (PT/OT, d/c plans)
Giving Feedback on Notes
• “Scut”  Teaching!
• Timing (end of day, interval options)
• Multiple notes (read all/review one, cull
comments)
• Plan to address identified student
issues
• If no/little progress, “demo” note
Author Contact Information
Tayloe Loftus, MD
[email protected]
Heather Harrell
[email protected]
(Provided progress note examples and has many more)