Developing good documentation skills can be a tremendous part of your training – with profound implications for your patients, the effectiveness of consults you request, your evaluations from attendings, and developing efficiency for your future work. I have been called several times, thanking me for my documentation – by malpractice lawyers, by risk management personnel, and once by the Chief of Medicine at another hospital – you would be surprised at the information that others find useful in your old notes.
Anyway, here are a few tips I extracted from the Documentation Module of the RookieDoc Members area… Let me know what you think in the comments below or through email.
1. Know who reads your notes – you may be shocked at how many people rely on your documentation. If you know who these people are and what they are looking for, you will be light years ahead of others in your program.
2. Write legibly – If you work in a hospital or office that does not yet use electronic records, you better write legibly. It can have a huge impact on patient care, lawsuits, and your evaluations from attendings.
3. Use bulleted lists – Most people scan notes to the parts they think are important. If you list things like Past Medical History, recent tests and studies, Past Surgical History, recent hospitalizations, etc as bullets in a list, it will make it much easier for people that read the chart after you. You will stand out and your patients will be better for it.
4. Indent consistently – when making paragraphs or headings, do it in a consistent fashion. Avoid writing everything in one big blob of a paragraph.
5. Consistent order of things – from note-to-note, stay consistent.
6. Refer to other parts of the documentation – It’s okay to write, “See Dr. Smith’s review of the CT results in his note dated 12/13” or “Exam is unchanged from 12/12” or “See #2 above”. A good example of “see #2 above” may be if you have to refer to a problem more than once… like renal insufficiency in it’s own section, and then also again under diabetes.
7. Ask for specific feedback – ask attendings, risk management nurses, and upper level residents to look at your notes and give you feedback. And don’t accept answers like, “They’re good. Keep it up.” No. Ask specifically, “Well, what could I do better? What should I work on?”