Tips for Your Note Style

Written by Annie Kopera, DO

Although we all write notes to some extent in medical school, most of us have a lot of growing to do at the start of intern year when it comes to developing our note style. Keeping organized and thorough notes can help you remember important details about your patients, present clearly and confidently on rounds, and can give you a great reputation in your program and among consultants. This post is targeted toward the assessment and plan portion of notes in Internal Medicine and its subspecialties.

#Problem list

Before starting residency, the hashtag method of creating a problem list was foreign to me, and this varies by institution. Rather than numbering diagnoses, hashtags are instead used in front of each diagnosis so that as you add more, you don’t have to adjust all of your numbers. Problem-stacking is another useful tool. If you want to highlight two separate diagnoses but feel it makes the most sense to discuss them together, then it may make sense to stack them together. For example, if a patient has sepsis secondary to an abscess, you can stack these problems together. Remember to reevaluate your problem list frequently to put the most relevant, pressing issues at the top.

#Keep “assessment” and “plan” separate

When trying to get notes done quickly and efficiently, you may find yourself simply using bullets for important topics. This is fine to do as long as you keep your assessment and plan separately. If you use the bullet method but don’t separate your assessment and plan, it can be very confusing to figure out what is going on with that problem. My preferred method is writing my discussion about the working diagnosis, including important lab and test results, in the past tense in a paragraph. Below the paragraph, I will list my plan using bullets. This way, everyone reading my note knows the plan. The benefit of writing in paragraphs in the past tense is that you are actively making your hospital course/discharge summary in your daily notes, so this does not have to be a separate task on the day of discharge. If writing sentences is something you prefer to leave back in AP Lit, you can also use have a separate “assessment” and “plan” section under each diagnosis, and only use bullets. The key here is that even though you are not writing in sentences, you are keeping your action items separate from your assessment.

Example below:

#Sepsis (WBC, HR)

#Abscess

Sepsis was present on arrival with an abscess as the source, and labs notable for a WBC 14 and HR of 110. CT scan obtained showed involvement of skin and muscle. General surgery was consulted.

· Obtain blood cultures x2

· Start Zosyn 3.375 q6h

#Do risk stratify

In your assessment portion, be sure to provide risk stratification for your problems. For example, if the patient has atrial fibrillation, calculate their CHADS2VASc and HAS-BLED scores. You will learn more of these scores throughout your residency!

#Keep a checklist

At the end of each note, keep a general patient care checklist of things important to know, but easy to forget. Mine includes:

· Code status

· Contact

· COVID vaccination

· Diet

· DVT prophylaxis

· Disposition

Others like to include a bowel regimen, and this checklist gets more complicated in the ICU, but for the floor, this will do!