Notes on Notes

Hi everyone:

One of my first projects as Program Director was to codify the “Yale Way,” our system for note writing and presenting on rounds. The Yale Way isn’t unique to Yale, of course; other institutions use the same method, more or less. But codification works. It ensures we all speak the same language and tell stories that are thorough, concise, efficient, lucid, and easy to follow.

This is the time of year to establish good habits, so with that in mind, I offer these notes on notes:

1. Make the Chief Concern (CC) a full sentence. Fragments (e.g., “abdominal pain”) lack context. Tell us the patient’s name, age, gender, and relevant background information. For example:
   1. CC: Mr. Jones is an otherwise healthy 21-year-old man presenting with one day of worsening right lower quadrant abdominal pain.
   2. CC: Ms. Smith is a 45-year-old woman with a history of ulcerative colitis, presenting with 5 days of crampy abdominal pain and bloody diarrhea.
   3. CC: Mr. Washington is a 68-year-old man with atrial fibrillation and severe peripheral vascular disease, presenting with sudden, excruciating abdominal pain.
2. Put the Past* Medical History (PMH) in the PMH section. Sometimes, I feel like I’m at the beach, drowning in a tidal wave of saltwater, seaweed, sand, shell fragments and fish parts:
   1. An atrocious CC: Ms. Thompson is a 57-year-old woman with obesity s/p gastric bypass in 2014, Type 2 DM on metformin, poorly controlled hypertension, hyperlipidemia on atorvastatin, Vitamin B12 deficiency, asthma, migraines, gout, DJD, anxiety, past IVDU, presenting with a sudden severe headache. If you can focus when you read this, more power to you. I can’t.
   2. A better CC: Ms. Thompson is a 57-year-old woman with a history of multiple medical problems, including poorly controlled hypertension, presenting with a sudden severe headache. Relegate the miscellaneous details to the PMH.
3. State where you got your information. Patient, family members, prior records, etc. Tell us if information is missing. Review old records, including the Epic Media Section and Care Everywhere. We found old PFTs on a Fitkin patient yesterday, which transformed how we viewed her illness.
4. Tell the HPI in order. Your goal isn’t to write a modernist novel that no one can follow. Start at the beginning:
   1. This works: “The patient was in her usual state of health until...”
   2. Create a timeline referring to the day of admission: “5 days prior to admission, this happened; 2 days prior to admission, this happened; on the day of admission, this happened, etc.”
   3. For patients admitted through the ED, highlight the main events: “The patient had a fever of 102 and a chest x-ray showing a right upper lobe infiltrate. She was started on ceftriaxone and doxycycline, and admitted to the floor”
   4. For patients transferred from other services, highlight the prior hospital course: “The patient spent two weeks on the ventilator, completed two weeks of vancomycin for MRSA pneumonia, had two left-sided chest tubes placed to drain an empyema, was extubated yesterday, and transferred to the floor today.”
5. Don’t put the Review of Systems (ROS) in the HPI. It’s common to confuse the ROS with pertinent positives and negatives. The ROS is a screening tool, a top to bottom survey, which we should ask of everyone. In your note, it goes just before the physical exam. In contrast, pertinent positives and negatives are targeted descriptions of relevant symptoms, essential to a thorough history. For example, in a patient with a fever, pertinent positives point to the diagnosis (“The patient described chills, cough, rusty sputum, and right-sided chest pain that worsened with inhalation”). Pertinent negatives point away from associated complications (“He denied shortness of breath”) and rule out other diagnoses (“He denied headache, neck stiffness, nausea, vomiting, diarrhea, dysuria, and rash”).
6. Humanize your patients. Use “woman,” not “female.” Use “man,” not “male.” Without being gratuitous, enrich your story with special information (a guitar player, an avid gardener, a retired teacher, a standup comic, etc.).
7. Elaborate on the key parts of the physical exam. If a patient has lymphadenopathy, supply the details: Where? How many? Mobile? Size? Tender? Consistency (firm, rubber, hard, matted, etc.)? Do the same for the heart exam in a patient with endocarditis, the neuro exam in a patient with altered mental status, and the lung exam in a patient with asthma.
8. Provide context for test abnormalities. New abnormalities demand immediate attention; old abnormalities may not (unless they’ve been overlooked):
   1. “The creatinine is 2.4 today, up from 1.2 yesterday.
   2. “The chest x-ray shows a 2 cm speculated right upper lobe nodule, new from a year ago.”
   3. “The hemoglobin is 8.1, unchanged from her baseline.”
9. Start your assessment with a summary. Patients can be really complicated. Highlight the relevant details and filter out the rest. For example: “In summary, this is an elderly woman with longstanding dementia and dysphagia who resides in an ECF, presenting with fever, hypoxemia, and a new right lower lobe infiltrate, one day after aspirating tube feeds.”
10. Create a complete problem list. If you mentioned it in your note, you own it. Go back to your CC. If the patient presented with fatigue, that’s a problem. If you found a goiter, that’s a problem. If the ultrasound showed a renal mass, that’s a problem. Some problems can and should be grouped, like thyromegaly, tachycardia, tremulousness, and a low TSH. You need to decide what to group and what to separate. Above all, don’t identify a problem in the first part of your note, just to let it drop at the end.
11. Think before you plan. Assess. Show your work. What’s your differential diagnosis? What’s most likely (“minor neck trauma”)? What’s less likely but still a “can’t miss" (“cervical spine fracture")? Why do you think the patient has SIADH? How do you know she isn’t volume depleted? Do you think HCTZ is contributing? Tell us.
12. List action plans. Create a list, and don’t use the plan section to repeat data or share observations (e.g., “s/p 14 days of ceftazidime”). Use bullets, first workup, then treatment:

• Check blood cultures
• Obtain an echocardiogram
• Start vancomycin and pip-tazo
• Consult ID

Baker’s dozen. Seniors- remember to attach a succinct addendum to all Intern H&Ps. You contributed to the patient’s workup. We need to see your thoughts.

This list is incomplete, of course, and I’d love to hear your ideas. Remember, we can’t take great care of our patients if we don’t communicate well. Look over your notes. Make them memorable. Things of beauty. And think before you sign.

With that, I’m off to join my Fitkin team.

Mark

*Why do we call it the “past” medical history? Is there a “future” medical history?

PS Wriggling by me yesterday on a climb up East Rock:

MDS