How notes help you think

It was 8 PM. Late. My attending called me. 

"Hey Robert, I was sitting to write my note and realized something..."

This isn't about what he said next, but what he had already said.

Despite pre-rounding then discussing with a team of residents, something hadn't clicked until he sat to write his note.

That's important.

I call it synthesizing...

It's the ACT of documenting that forces you to think through a patient's case. Rush it and you're rushing through an important tool for clinical reasoning.

Medicine is fast but at times we must think slow...

Details and how they relate may not be clear until the different pieces of a patient's puzzle are in ONE place. A note. Good documentation calls for an assessment, something we may fail to do until we slow down and put "pen to paper."

A note becomes the ultimate check list...

Did you treat their hyperkalemia but forgot they're on spironolactone and lisinopril? If those meds are listed under their appropriate sections, you'll remember then.

Good care is thorough.

A good note is thorough.

Good notes are good care.

For both you and patients.

Question / Answer

Synthensizing in the HPI

I teach that it's good practice to only select 3 - 4 pertinent comorbidities / chronic medical conditions in your HPI. Do NOT copy and paste a problem list. This gives you a moment to relate the chief complaint to these comorbidities. I've seen copy/pasted problem lists in an HPI including FIFTEEN problems where a patient, who obviously had malignant pleural effusions, was treated for heat failure. If the doctor had taken a moment to review the problem list, the diagnosis would have been much more obvious.

Synthesizing in the Physical Exam

Thankfully, with the new 2023 billing updates the days of templated checkbox physical exams should fade. Free texted exams will allow more freedom and more critical thinking while documenting it. Physical exam components that you forgot to check or groups of findings which point to an underlying diagnosis sometimes become clear while documenting the physical exam.

Synthesizing in the Assessment & Plan

We are often busy reacting in medicine. Sitting to write an assessment (which you must intentionally do, current EMR's are not conducive to this) is a moment to critically think about a diagnosis. The act of writing (typing) your clinical reason from Point A to Point B to Point C may expose gaps in that reasoning and make you reconsider. We unintentionally allow ourselves gaps in our reasoning in our minds. You cannot do that in written words.

How is this important for CDI Specialist?

CDI is not just CMI, RAMI, ROI, etc. I'd like to see CDI professionals take "integrity" a bit further: to stewardship. This is a word that has much more meaning to doctors. Just like antibiotic stewardship, where we are careful about the use of antibiotics as their misuse can have negative consequences, we should promote "documentation stewardship" as the improper use of notes can have negative consequences. This would include teaching on why documentation benefits physicians and patients, as I detailed above. Improve the relationship between physicians and their documentation (something they see as a burden... and it is due to increasing patient loads and time constraints) and the rest of your CDI priorities will follow suit.

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

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