Writing in the notes

I'm planning to post a series of guides on this that I'll later promote to articles and add to the forum navigation. The first one is on writing progress notes but I'll do one on admission notes later as well.

As a medical student on the wards you’re allowed to slowly take on some responsibility for ward work and one of the things you can really be of help with is writing in the notes. While this sounds like a simple task, and is a simple task, it’s one that can be done well or done poorly. In particular I remember during my pre-internship term the fellow writing in the notes for the consultant ward-round and being stunned by how efficient and effective she was. You wouldn’t think there’d be that much room for improvement with such a simple task but clearly there is. To be fair, part of her advantage was being so senior and knowing what the consultant was thinking the whole time.

This is a topic that is loosely taught in medical schools so I hope this guide will be more comprehensive. What’s worth considering is that effective progress notes are a god-send when you’re writing discharge summaries or reviewing a patient you don’t know and it’s so much help to have them written well. You can really make a difference here.

1. Housekeeping
This is the bare bones of what all medical notes should include. You can’t skip out on this part, it has to be there for medico-legal and common-sense purposes.

• Date and time: This is important for knowing what happened when. The time is, if anything, more important than the date. That can usually be worked out from the nursing notes if necessary but time cannot. Do not fall forget to record the time.
• Position: for a consultant led ward round this might start with S/B Smith + team. S/B stands for seen by and usually (but not always) implies the name following is that of a consultant’s. In a registrar led ward round you might write Gen Surg WR Jones (Reg)/Chan (Intern), the more info you write here the better but on a speedy surgical ward round you might need to abbreviate. If you have time write also + students or your own last name /Lim (student)
• Sign: If you write in the notes you have to sign at the end, ideally with your printed name underneath it and your designation e.g. signature, underneath that last name, underneath that student. YOU MUST ALWAYS GET A COUNTER-SIGNATURE. If this is impossible on a speedy surgical round still try your best to get the signature or let the JMO know after the round which notes are missing counter-signatures.
• Contact: a medical student doesn’t need to do this but the person writing the notes should also include a pager number or something they can be contacted on. The intern who counter-signs your notes should include this.
• Sticker: always check to make sure the piece of paper you're writing on has a patient ID label sticker on it and put one on yourself if it isn't there

2. Format
A well known and easy to use format for actually writing in the notes is SOAP. It stands for subjective (what the patient tells your or the ‘history’), objective (what you find on examination), assessment (what you think is going on), and plan (what you’re going to do about it).

Ideally a progress note should also include an introductory statement that the patient’s reason for admission and progress so far.

• Subjective: Only include things that are relevant, do not write everything the patient says (but have a low threshold for what may or may not be relevant when you’re junior). Things like how comfortable the patient is, whether they are in pain, whether they are eating and drinking (or when they last ate or drunk) and how much, whether they are passing urine and opening their bowels (when last, how much), and whether they are walking are almost always relevant.
  
  • Note: if you’re ever asked to ‘go and start seeing the patient’ while the registrar is doing something else asking them about six things: pain, eating, drinking, urine, bowels, and mobilising (walking) is always a good idea. This is mostly because if they can do all of those things it’s a trigger to start thinking can I send them home.

• Objective: Ideally this will follow a very set and straight-forward structure. Start with a one- liner about how the patient looks (e.g. well/sick/critical/in-pain/sleeping).
  
  The next section should include the most recent vital observations (heart rate, respiratory rate, blood pressure, temperature, saturations). If you’re stuck for time only include the most relevant ones (e.g. post-operative patient progress notes must always include some reference to temperature – their current temperature or afebrile if no fevers since the last note, or their last fever and its time if there was a fever between the last note and this one).
  
  The next section is for drips, drains and such things and is most relevant for surgical patients. If they have a urinary catheter or surgical drain in situ you should record their volumes over the last 24 hours. In a medical patient you might need to include their fluid balance from a chart. Some patients won’t have anything relevant for this section
  
  Then, are the systems examinations. Usually they will include one or more of HEENT (head, ears, eyes, neck and throat), resp, cardio, abdo, neuro and peripheries). It’s good to specifically write HEENT/Resp/CVS/Abdo/Neuro with a colon after it to signify this or else use a picture. I’ll explain this part further in a guide to writing admission note.
  
  This is also the place to include pertinent investigation results. Such as blood results e.g. CRP: 120 or K+ 5.7 and imaging e.g. CXR (chest X-ray) normal

• Assessment: This is also known as impression and can be as simple as a one line statement such as ‘safe for discharge’ or ‘awaiting nursing home placement, or ‘unable to mobilise, requires on-going physio’, or ‘stable, awaiting operation’. It can be very difficult to know what the ‘assessment’ is as a medical student and you might need to ask the registrar. Often this part is left out of the notes but it’s very useful to have in there.
  
  Ideally this section will also include a differential diagnosis or an problem/issue list. An example of an issue might be e.g. unable to mobilise, or needs placement, or persistent fevers, or hyponatraemic (low sodium) with 123 in brackets

• Plan: This is a numbered list of things you’re going to do for your patient and every progress note must have this even if it simply states ‘continue, no changes’. Things this might include are ‘arrange out-patient MRI’, ‘repeat electrolytes’, ‘encourage oral hydration’, ‘start IV antibiotics’

Great guide so far! Keep it up, doc', really helpful stuff.

Is there any/lots of note-writing in 4th year? Are there expectations of students in terms of how good we can write? I'm a bit nervous about the whole thing, I've had a tiny bit of practice which I've mostly forgotten, and to top that off I'm a slow writer with messy writing. If I go faster, it'll get messier. What do :S

Good old SOAP. Very informative, thanks Matt!

Everyone develops their own style for writing in the notes but these symbols and diagrams are fairly commonly recognised and effectively give a lot of information very quickly.

Originally Posted by n33b

Is there any/lots of note-writing in 4th year? Are there expectations of students in terms of how good we can write? I'm a bit nervous about the whole thing, I've had a tiny bit of practice which I've mostly forgotten, and to top that off I'm a slow writer with messy writing. If I go faster, it'll get messier. What do :S

In medical and surgical terms (often in other terms as well), you'll be expected to write in the notes as a student. Often the intern will appreciate it because it means they can write down jobs in their own patient list while you do the note-taking part. When you first start as a clinical years student though you shouldn't write in the notes until you've been taught how to do it and you feel comfortable doing it. Once you feel comfortable though you should take the lead and offer to write in the notes unless your intern or resident wants otherwise. When I first started I was initially allowed to write the notes for simple patients but the registrar would get the intern to write if they were complicated. The most important thing is probably to make sure you have the plan down properly. Hence if on a round the consultant or registrar starts mentioning something like 'lets stops the IV fluids' I'll skip straight to writing that in the plan 'cause the house-keeping stuff can always be fixed up later, similarly the history and exam stuff is arguably of less importance to get down correctly than the plan is.

As to practice and what to do, you always need to have a system so that you don't forget things. Use SOAP and don't forget the housekeeping stuff and you should be fine. It's ok to write messy as long as it's legible, write as fast as you can while staying legible. If you can't write fast enough prioritise the important stuff (i.e. the plan) and fix up the rest of it after the team has moved on to the next patient. The intern can write the notes for the next patient if you're still busy fixing up what you've done, it is, after all, their responsibility and not yours.

The admission note for a patient is really important. For the nurses it signifies that the medical team treating the patient is aware of them and their current level of stability and that there is a plan in place for their admission. For the doctors involved in treatment it is one of the most read entries in the notes because it provides a summary of why the patient is in hospital, and their background. This is crucially important for an after-hours doctor reviewing a patient they may not be familiar with or if another medical team is consulting on the patient. When it comes time to write the discharge summary the admission note is also really useful.

1. Housekeeping, this is the same as for progress notes, see this post here.

2. Format, most formats used in admission note follow a similar structure. A typical outline might be as follows:
- Presenting complaint (often abbreiviated PC or CC (chief complaint))
- Past medical history or Background (PMHx)
- Medications (Meds)
- Allergies
- History of presenting complaint (HoPC)
- Review of Systems (RoS)
- Social history (SHx)
- If relevant family (FHx), occupational, and travel history
- The Physical examination (O/E stands for on examination)
- Laboratory and imaging studies (Ix)
- An impression (Imp) and/or a differential diagnosis (DDx) and/or a problem list (Issues)
- The plan (sometimes simply ‘P’ with a circle around it)

The order of these will depend on the person writing the notes. In many textbooks the HoPC comes before the PMHx, Meds and Allergies however it makes more sense to include those three things first unless the patient does not have any medical records. This is because (1) they are kind of details you want to be able to find quickly by flicking to the front of the notes, (2) it’s usually easier to be clear on these details before you take the HoPC as the patient may not be certain about them and your notes end up messy and less user-friendly if you have to go back and add things. The order, however, is of relative unimportance so long as the information is there.

The presenting complaint is a one or two line summary that aims to concisely identify the crux of the patient’s presentation. The diagnosis may be clear by the time you see the patient (e.g. ED have already worked them up or they’ve been sent in by their GP or specialist) or it may not be. If it is you include the diagnosis if not you include the presenting complaint. For example:
- A 66 year old man presents with non-critical aortic stenosis with a background of obesity, T2DM (type 2 diabetes mellitus), and HTN (hypertension)
- A 66 year old man presents with a ²/₅₂ history of exertional angina and a systolic murmur
It is sometimes best to leave the a space for the PC and fill it in after you’ve finished seeing the patient.

The past medical history may be separated into past surgical/psychiatric/obstetric etc history. It should include a list of the patients diagnoses and ideally the year they were diagnosed, the doctor who manages it, and sometimes some indication of their stage of treatment. For example:
- T2DM 1998, known to Dr. Jones (Endocrinologist), on 32 units of insulin (T2DM can be treated with diet alone, medications or insulin in that order according to severity)
Usually this information can be gleaned from the medical record, alternatively you might consider calling the patient’s GP or their specialist’s reception and asking them to fax over relevant correspondence. You’ll be thankful to an intern who writes a good discharge summary for finding this information quickly. Be aware that old medical records may not be consistent with the patient’s current medical history

Medications and Allergies are also usefully gleaned from the old medical record but it is very important to confirm these with the patient because (1) medications change frequently or they may not be adherent to their medications, (2) allergies are things that need to be checked 2, 3, 4 or more times over.

The history of presenting complaint is a more comprehensive exploration of the PC. Typically it is organised according to a symptom. For example, medical students are commonly taught how to take a ‘pain history’ and the details of this would go here. This requires a lot of skill and knowledge, however, because there are many different presentations. For example a patient presenting with shortness of breath in the context of asthma might be asked the standard shortness of breath questions as well as an ‘asthma history’ e.g. have you been in hospital for your asthma, have you ever been in ICU, do you take steroids orally, what are your triggers, how often do you need to use your relievers, as well as questions to assess if there is any underlying psychiatric conditions (which are unusually common among asthmatics).

The Review of Systems is a umbrella, catch-all, series of questions designed to minimise the chances of anything serious being missed. It includes for example, regarding the cardiovascular system: chest pain, palpitations, paroxysmal nocturnal dyspnoea, ankle swelling etc. For the urinary system: polyuria, nocturia, dysuria, frequency, incontinence, flank pain etc. It is upper to the person taking the history as to how extensive the RoS is but should minimally include a brief overview of the cardiac, respiratory, abdominal, urinary, and neurological systems.

The social history is a common pit-fall in the admission note for being too brief. Often it will simply include the patient’s smoking status (which should be recorded in pack years as well as making it clear whether the patient is a smoker/non-smoker/ex-smoker) and alcohol consumption (which should be recorded in standard drinks per day or week – it’s ok to estimate this).

A SHx should include more than just that though. Typically it should also include where the patient lives (e.g. own home, low-level self-contained aged care, nursing home) and whether it has been modified for their disabilities and/or if there are stairs to climb; their level of independence (e.g. do they need a walking aid, can they attend to their own hygiene, finances, etc) and how they get around (can they drive). It is also worth assessing how much support they have from family/friends.

Other things that may be important include pets, nutrition, sleep quality/hygiene, their most pressing problems (e.g. they may be a carer for their wife/husband), and their hobbies/interests.

A family history is important for (often rare) inherited conditions, most cancer patients, and all patients presenting with chest pain (a first degree relative in their 50s if male or 60s if female – or younger – is a significant risk factor for ischaemic heart disease). Occupational history may be important for, as an example, heavy-lifting requirements after abdominal surgery. Travel history is relevant for exposure to infections like tuberculosis or malaria, and risk of developing clots in the leg through not moving around on an aeroplane for long periods of time.

Many textbooks have been written on the examination so I won’t go into it in detail except to offer a mnemonic for its structure, the commonly used ABCDEFG.
- Appearance: e.g. obese, well, unwell, in pain,
- BMI: an estimate along the lines of not overweight, overweight, obese or morbidly obese is ok
- Cognition: often simply whether they are alert and interactive, if this appears not to be the case whether they are orientated to time, place and person and if necessary further questions up to and/or including a mini-mental status examination
- Devices and attachments: this is things like IV cannulas (IV lines), indwelling urinary catheters, drainage bags, stoma bags, prostheses, nasal prong oxygen, etc.
- Entire body: usefully divided into HEENT (head, ear, eye, nose throat), Cardio, Resp, Abdominal, Neuro, and Muskuloskeletal
- Functionality: tests of function may be relevant especially the timed ‘get-up-and-go test’
- Gait: may be relevant e.g. normal/safe, antalgic, scissor (e.g. cerebral palsy), ataxic (e.g. drunk, cerebellar), shuffling (Parkinson’s), high-stepping (foot drop), circumduction (stroke), wide-based, trendelenberg (hip pain).

Laboratory investigations and imaging will usually include things like Na⁺/K⁺/Urea/Creatinine, Haemoglobin (Hb)/White Cell Count WCC/Platelets (Plts), Ca⁺⁺/Mg⁺⁺/PO₄^-, and perhaps albumin/bilirubin/GGT/ALP/ALT/AST for laboratory investigations. Other investigations will depend on the patient (e.g. troponins in a patient with chest pain)

12 lead Electrocardiograms (ECG) are often relevant here (again, in chest pain, something like no acute changes or no ST deviation or T wave changes).

Chest X-rays (CXR) and Abdominal X-rays (AXR) with a brief summary of the key findings.

The impression will usefully include what you think is going on e.g. chest pain, cannot exclude a cardiac cause. Or Acute pulmonary oedema secondary to AF secondary to ? with a DDx such as ischaemic heart disease, cardiomyopathy, thyrotoxicosis, ethanol, idiopathic etc. The problem (or issue) list will include similar things described to in the progress note post above.

The plan includes things the medical team intends to do for the patient and orders for the nursing and other staff. It is usefully divided up into plans for further investigation e.g. repeat ECG, check thyroid function tests, telemetry bed on the ward, chase correspondence from GP; plans for treatment e.g. increase metoprolol to 100mg BD, restrict fluid intake to 1.2L; and plans for patient logistics e.g. admit under Dr. Jones, transfer to rehabilitation, or discharge home.

Aside from an admission note or a progress note the other type of entry in the notes worth familiarising yourself with is the clinical review note. In NSW hospitals a nurse will call the junior doctor to review their patient if any of their observations do not fall ‘between the flags’ (high ADDs score in QLD), but a nurse may ask to review the patient for other reasons such as a high blood sugar or pain.The structure of this note will, again, depend on the person writing it. The format outlined here though is commonly used and, I think, a useful way of doing things.


1. Housekeeping, this is the same as for progress notes, see this posthere. While it is important in every note you write, including the time in a clinical review note is mandatory. The position, which you write at the very top, will also read differently. Typically, it will be something like Intern after-hours or JMO after-hours.

If you are a medical student, you should write something like ‘medical student for Intern after-hours’. If you write a plan remember it must be counter-signed by a supervising doctor. Most medical students won’t be writing plans in clinical review notes, however, unless they are at a pre-internship stage or equivalent. Most medical students will simply write a clinical impression and in the plan state something like ‘will discuss with intern after hours’.

2. Format,

the format is much the same as an admissions note although abbreviated at times.- Presenting complaint (PC or ATSP)- Admission summary/chart review- History of Presenting Complaint (HoPC)- Focussed examination (O/E)- Relevant laboratory, electrocardiographic or radiographic findings- Impression- PlanThere are some key differences in the review note compared to, say, an admissions note which will be described here.

The presenting complaint, in this setting, is often referred to as asked to see patient or ATSP.
It might read, for example, something as simple as, “ATSP: fall out of bed”

The admission summary includes a one or two sentence concise summary of why the patient is here. For example, “82 year old gentleman admitted for investigation and management of persistent fevers and a decline in mobility” (note that this one sentence indicates the patient’s problem is a diagnostic one, suggesting the treating team are not yet aware of the diagnosis for this patient).

The chart review goes into this a little bit further. It should make some reference to the HoPC for this admission, for example, “progressive decline in mobility over last 3/12 with previous mechanical fall 2/52 prior to admission”. A summary of the past medical history, “previously fit and healthy, living in full independence with wife in own home”. Some reference should be made to any key examination findings, “bilateral quadriceps wasting noted at time of admission with 4-/5 power on the right and 4+/5 on the left lower limbs”. Investigations are also relevant, e.g. “Today’s WCC (white cell count) 13 with neutrophila, UEC (urea, electrolyte and creatinine) was normal, CT Brain at time of admission showed only age-related changes”. Finally, some reference should be made to team’s plan for this patient, “awaiting MRI spine on Tuesday”.Note that the admission summary/chart review is typically briefer than what you would find in the admission note. For clinical reviews a complete history and examination is not required, this should have been done at the time of the admission. Instead the purpose of the chart review is to familiarise yourself with the patient and focus your history and examination.

The HoPC, in this setting, may not be the same as their HoPC regarding the admission. It may be something like a blood pressure of 190/105 when the patient was actually admitted to hospital for acute back pain. In this case the acute back pain may be relevant to the clinical review HoPC (perhaps the high blood pressure is related to poorly controlled pain) or it may not be relevant at all. Similarly, the HoPC may be quite brief if you’re asked to see a patient about a blood pressure of 190/105 and they are completely asymptomatic. You would simply need to write the relevant negatives (e.g. patient denies chest pain, blurred vision, headache, or shortness of breath). Conversely, a fall out of bed requires at minimum a description of potential precipitating conditions (e.g. night time stat order of a sleeping tablet), what happened immediately prior to the fall (did they black out or lose consciousness?), injuries sustained during the fall (head injury, in particular is relevant), and how they felt after the fall (could they get up straight away, did they need help?). A falls history is quite extensive even if you’re only the after-hours doctor (often much to the distress of the patient who is already feeling insecure about their now slipping independence and who’d rather not go through it in detail).

The examination, like the history, need not be complete, this should have been done at the time of admission. It is focussed but will typically include- Appearance – does the patient look well, unwell, critical, in pain, confused- Vital observations, usually it’s enough to repeat the last measurements from the chart, sometimes it is more appropriate for you to measure them yourself or ask the nurse to repeat them just before you expect to arrive- HEENT/Cardivascular/Respiratory/Abdominal/Neuro/Musculoskeletal (but note some of these systems may be omitted where they are not relevant to the call)

Relevant laboratory, electrocardiographic and radiologic investigations

are also much less extensive in a clinical review setting and depend on the chart review, focussed history and examination so far. Common things that might be included here are ECG findings, finger-prick glucose, an arterial or venous blood gas recording, or a mobile chest x-ray. Sometimes you can order investigations in advance while you’re receiving a call, an ECG is a good example of this.

The

impression

is what you make of the patient and should not simply repeat what the nurse asked you to see the patient about. For example, “essential systolic hypertension in the elderly not requiring urgent intervention”, or “fall which reaching over bed in setting of urinary frequency, nocturia, and high dose nitrazepam”.

The

plan

in this setting is usefully divided up into those things you want to do immediately for the patient (e.g. repeat troponins and chest x-ray now), and those things you would like the team or more senior doctor to do when they see the patient later on (e.g. team to review anti-hypertensive medication mane (morning), or team to consider tapering night time benzodiazepine (sleeping tablets) or to handover to team mane.