The errors you inherit in notes

The most common way I see notes written is:

• inefficient

• unorganized

• predisposed to copy/forward errors (& thus medical errors)

What is this most common way? Copy/forwarding the previous note and editing here and there.

But the problem is you’re likely inheriting notes from colleagues who all have varying ways of writing their notes.

That means every note is different than the next. This is inefficient and mentally taxing.

One thing you must understand: Your brain is lazy. You put your keys in the same place every day, so you don’t have to go looking for them every morning.

Why treat your notes any different? Only edit the same parts every day and you don’t waste time searching for what you need to actually update and proof-reading walls of texts.

I’ll get into what I recommend but first,

Here are 5 ways I see notes written (and the different formats you might be inheriting):

1. Copy/forward everything

2. Copy/forward + edit here and there (most common)

3. Word-vomit stream of consciousnesses

4. Abbreviate everything for the shortest note possible.

5. Systematically formatting every note.

Let’s break those down:

1. Copy/forward everything

Pros:

• Fast (seemingly…)

Cons:

• Won't help you think or take care of the patient. (The process of writing helps you think)

• Your plan is copied from the previous day so other members of the care team will have to reach out to you to confirm your plan / your thoughts, costing you time

• Sets you up for litigation (by being loaded with copy/forward mistakes)

• Won't stand up to a billing audit (because it’s not true to that day)

2. Copy/forward + edit here and there (most common)

Pros:

• Seems efficient at first

Cons:

• Not ultimately efficient as each note is different than the next + lots of proof reading for you

• Plagued by copy/forward mistakes

• Your reasoning, hospital course details, and your plan are all jumbled together(aka unorganized). This is difficult for readers to find what they’re looking for. For you, these unorganized notes take you extra time to find what actually needs updating.

3. Stream of consciousness

Pros:

• Your thought process is well documented

Cons:

• Will be a lot for you to proofread tomorrow

• Your plan will be buried in a wall of text. Other team members won't know your plan and may have to reach out to you to find out. You’re contributing to information overload and scatter.

• May still not satisfy billing (I’ve seen paragraphs among paragraphs of notes that don’t meet billing requirements)

4. Short as possible

Pros

• Fast (seemingly…)

Cons:

• May lead to medical errors as abbreviations may not be understood by other team members. (Again, they may have to reach out to you, costing your more time)

• May not reflect well in court as this may make you look rushed and careless

• May not satisfy billing

5. Systematically formatting each note

Pros:

• Efficient

• Readable

• Protects you legally

• Can optimize for billing

Cons:

• You have to spend a little extra time reformatting when you inherit a note (but you save loads of time later)

I format my note to be as concise as possible. Each note is structured the same, so I know what I need to update each day. I delete A LOT of unnecessary wordiness with my first note.

Briefly, this is how I format each note:

1. I use problem-based formatting. Many keep problems as symptoms with the diagnosis listed under it. That’s unnecessary words. I replace the symptoms with diagnoses (if they’re clear / confirmed).

2. My first line under my diagnosis is always evergreen - meaning it’s true each day despite being copy/forwarded. I include information here that helps me stay organized / reminds me of certain details and I use dates instead of relative days. I keep this section quite limited. Not every problem requires this evergreen section.

3. Next, I organize my plan as a bulleted list. I keep it short, typically 3 - 5 points. This is the only section under each problem that I know I need to update each day. Lists with short sentences are quick to edit and much less prone to copy/forward mistakes vs long sentences or paragraphs. They are also “searchable” to reader’s eyes.

4. I delete medications and labs that are mentioned multiple times throughout the note. I mention those once and then refer back to those under other problems. This limits which problems I need to update and ensures accuracy of my note, so I don’t have medications both “continued” and “held” at the same time in my note (a frequent issue I see).

5. I keep the problems that actually need updating at the top of my note. The rest of the problems that might be some version of “as under xyz” are towards the bottom and I never update those as they themselves are evergreen. Yes, I do keep these other problems listed to remind myself of them so I can use my note as the ultimate checklist. Those other problems may jump to importance on subsequent days.

6. I delete lengthy explanations / reasonings. If it’s documented once, you do not have to copy/forward that every day.

Do you have to follow my format 100%? Absolutely not. But this format helps me stay organized and efficient while helping me synthesize, communicate my plan, protect myself legally and satisfy billing.

Anyone can, and should, develop their own format to match their needs and specialty.

That’s all for now. I hope that’s helpful.

Please feel free to reach out and ask questions as they help inspire future issues!

Cheers,

Robert

When you’re ready, there are two ways I can help you:

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