As a medical student on the wards you’re allowed to slowly take on some responsibility for ward work and one of the things you can really be of help with is writing in the notes. While this sounds like a simple task, and is a simple task, it’s one that can be done well or done poorly. In particular I remember during my pre-internship term the fellow writing in the notes for the consultant ward-round and being stunned by how efficient and effective she was. You wouldn’t think there’d be that much room for improvement with such a simple task but clearly there is. To be fair, part of her advantage was being so senior and knowing what the consultant was thinking the whole time.
This is a topic that is loosely taught in medical schools so I hope this guide will be more comprehensive. What’s worth considering is that effective progress notes are a god-send when you’re writing discharge summaries or reviewing a patient you don’t know and it’s so much help to have them written well. You can really make a difference here.
This is the bare bones of what all medical notes should include. You can’t skip out on this part, it has to be there for medico-legal and common-sense purposes.
- Date and time: This is important for knowing what happened when. The time is, if anything, more important than the date. That can usually be worked out from the nursing notes if necessary but time cannot. Do not fall forget to record the time.
- Position: for a consultant led ward round this might start with S/B Smith + team. S/B stands for seen by and usually (but not always) implies the name following is that of a consultant’s. In a registrar led ward round you might write Gen Surg WR Jones (Reg)/Chan (Intern), the more info you write here the better but on a speedy surgical ward round you might need to abbreviate. If you have time write also + students or your own last name /Lim (student)
- Sign: If you write in the notes you have to sign at the end, ideally with your printed name underneath it and your designation e.g. signature, underneath that last name, underneath that student. YOU MUST ALWAYS GET A COUNTER-SIGNATURE. If this is impossible on a speedy surgical round still try your best to get the signature or let the JMO know after the round which notes are missing counter-signatures.
- Contact:a medical student doesn’t need to do this but the person writing the notes should also include a pager number or something they can be contacted on. The intern who counter-signs your notes should include this.
- Sticker: always check to make sure the piece of paper you’re writing on has a patient ID label sticker on it and put one on yourself if it isn’t there
A well known and easy to use format for actually writing in the notes is SOAP. It stands for subjective (what the patient tells your or the ‘history’), objective (what you find on examination), assessment (what you think is going on), and plan (what you’re going to do about it).
Ideally a progress note should also include an introductory statement that the patient’s reason for admission and progress so far.
- Subjective:Only include things that are relevant, do not write everything the patient says (but have a low threshold for what may or may not be relevant when you’re junior). Things like how comfortable the patient is, whether they are in pain, whether they are eating and drinking (or when they last ate or drunk) and how much, whether they are passing urine and opening their bowels (when last, how much), and whether they are walking are almost always relevant.
- Note: if you’re ever asked to ‘go and start seeing the patient’ while the registrar is doing something else asking them about six things: pain, eating, drinking, urine, bowels, and mobilising (walking) is always a good idea. This is mostly because if they can do all of those things it’s a trigger to start thinking can I send them home.
- Objective:Ideally this will follow a very set and straight-forward structure. Start with a one- liner about how the patient looks (e.g. well/sick/critical/in-pain/sleeping).The next section should include the most recent vital observations (heart rate, respiratory rate, blood pressure, temperature, saturations). If you’re stuck for time only include the most relevant ones (e.g. post-operative patient progress notes must always include some reference to temperature – their current temperature or afebrile if no fevers since the last note, or their last fever and its time if there was a fever between the last note and this one).
The next section is for drips, drains and such things and is most relevant for surgical patients. If they have a urinary catheter or surgical drain in situ you should record their volumes over the last 24 hours. In a medical patient you might need to include their fluid balance from a chart. Some patients won’t have anything relevant for this section
Then, are the systems examinations. Usually they will include one or more of HEENT (head, ears, eyes, neck and throat), resp, cardio, abdo, neuro and peripheries). It’s good to specifically write HEENT/Resp/CVS/Abdo/Neuro with a colon after it to signify this or else use a picture. I’ll explain this part further in a guide to writing admission note.
This is also the place to include pertinent investigation results. Such as blood results e.g. CRP: 120 or K+ 5.7 and imaging e.g. CXR (chest X-ray) normal
- Assessment: This is also known as impression and can be as simple as a one line statement such as ‘safe for discharge’ or ‘awaiting nursing home placement, or ‘unable to mobilise, requires on-going physio’, or ‘stable, awaiting operation’. It can be very difficult to know what the ‘assessment’ is as a medical student and you might need to ask the registrar. Often this part is left out of the notes but it’s very useful to have in there.Ideally this section will also include a differential diagnosis or an problem/issue list. An example of an issue might be e.g. unable to mobilise, or needs placement, or persistent fevers, or hyponatraemic (low sodium) with 123 in brackets
- Plan:This is a numbered list of things you’re going to do for your patient and every progress note musthave this even if it simply states ‘continue, no changes’. Things this might include are ‘arrange out-patient MRI’, ‘repeat electrolytes’, ‘encourage oral hydration’, ‘start IV antibiotics’