Step-by-step guide to writing medical school notes - TheMDJourney (2023)

Have you ever felt stressed when told that you have your progress notes ready by a certain time? Have you ever spent more than 30-45 minutes writing your notes? Don't know what to add and sometimes you add too much? Finally, what is a consistent method for taking notes in medical school?

In this post, I'll cover a step-by-step approach to writing notes in medical school. This is a technique that you can use every morning to not only take your notes, but to do well.

I assume we mean pre-visit notes from our patients. When you are in the clinic, the procedure is similar.

First thing in the morning I have a structured way of collecting data overnight.

I open my progress note template. The template is something I created ahead of time, and it breaks down my rating in typical SOAP (subjective, objective, assessment/plan) format. Since I have a template, I can only enter the events for the night, the new vitals, the physical stats for the day, and the plan for the day.

First I read the notes from my last progress note. I pay attention to important events, new symptoms or expert recommendations in the subjective part of my note. Don't worry about grammar or spelling now. We will make final adjustments later.

Then I move on to vital signs. I write down heart rate, blood pressure, and temperature ranges in my notebook. If you notice abnormal values ​​at this point, pay attention to the time(s) these abnormalities occurred. If your patient has a nocturnal tachycardia, everyone will want to know why.

Then I review the medication my patient has received in the last 24 hours. Focus primarily on the dose/frequency of pain relievers and fluids received.

Lastly, look at the lab results.

Use this strategic approach and easily take notes in medical school.

Even before seeing your patient, you now have a 75% complete grade. Because the flow of information becomes second nature, you can complete that first draft of your note in just 10-15 minutes.

After completing your note, add the questions you need to ask your patients.

One of the best ways I know of to write effective notes is to have effective interactions with patients. You do not have to go in and out of the patient's room. At the very least, this leads to poor recording and presentation. Instead, use the information you've collected about your patient over the last 24 hours and consider what to ask and investigate.

For example, if your patient has episodes of nocturnal tachycardia, ask about OBS, palpitations, fever, and UOP. These questions will help you differentiate between pulmonary embolism, infection, arrhythmias, and/or shock.

If you walked into your patient's room without a plan right now, you probably would have forgotten some of these questions.

You'll look more impressive in front of your team if you get past them and start ruling out diseases based on your questions.

After viewing your patients, enter your patients' responses to your question and add anything relevant they mention.

You now have a nearly complete note that requires minimal effort.

The last thing to get a perfect score is to come up with a plan. Yes, you can simply ask your resident for the plan.However, this is the quality of a "passed" student.

To gain honor (without being obnoxious), come up with a plan for your patients.Do you need new medications? Should you consider buying images? Is the layoff schedule changing in any way?

Consider all of these issues, find possible solutions, and present these ideas to your resident. You will probably miss something. This is completely correct. You work hard and care about your patients.

Once they indicate the actual plan, add it to your note and fill it out.

Finished!

Now you understand my step by step guide on how to write med school notes every morning.

I was praised by residents and attendees for my concise and informative notes. Below I've added additional tips I use to write quick but quality notes.

I have seen many notes where the topic is just one long paragraph. You have to work hard to find exactly the information you need. Once you find it, expect the quality of the information to be good.

Instead, break your patient's problems into paragraphs. For example, I recently had a patient in an OB/GYN clinic with dysmenorrhea and palpitations. I could have written all her problems in one paragraph. No one will read the "book" the medical student wrote.

Instead, share your problems. I started the first paragraph with "The patient complains of (insert symptoms)." Then I add all the information related to this problem in chronological order of how the symptoms of it have presented. This is the same approach I use when presenting. look at my postPresent patients to the medical school.Learn more.

The second paragraph could read "in relation to the patient's complaint of (symptom B)". and add the appropriate information.

Now your reader can look at your note and focus on one topic at a time.

If you look at your patient's medical record and can't identify a flow, you need to restructure it. Make sure each issue is separate. Include a description of the symptoms and the actions taken with each problem.

Below I've written a quick example of what a topic might look like in one of my notes.

“The patient is a 38-year-old woman with PMH due to HFFERHF (FE 35% after Eco 01/20/2012), DM2 (A1C 8.9% 05/17), who presented on 02/17/18 with SOB and lower limb edema.

The overnight patient claims that the SOB has improved. He received Lasix 40 mg x 2 yesterday and the patient reports good UOP (1000 cc per table). The patient was able to move around the room without difficulty. He denies a productive cough, headache, dizziness, or fever.

Regarding the edema of the lower limbs, the patient reports that the size of her lower limbs has returned to baseline. She no longer complains of pain when walking.

The patient has a new complaint of constipation this morning. No BM for two days. Still passing apartments. He has tolerated PO and received PO. ”

pop! The note is divided according to the patient's problems and you can go from one paragraph to another depending on what you want to know.

I was in rotation with classmates who take hours to write their notes. God bless their hearts, but they tried to be too perfect.

Short story: A medical student's grade has very little value (if any).

So use the approach above to write a thoughtful and efficient note. but don't spend most of the day writing your notes.

The most important thing is to be consistent with the rest of your team. Do not add a plan to your note that is the opposite of what your team is doing for the patient.

This is confusing to anyone who reads your note and doesn't realize it was written by a medical student. They can add weight to your plan, which may not be entirely true.

That's why it's important to confirm the plan with your resident. If you notice a discrepancy later, add your note.

Also remember, even if no one can read your note, pretend it's the only one that matters.

This means not going into unnecessary detail and drawing a solid picture of the patient's complaint.

At times I have used notes from colleagues to better understand a patient's condition and care. Residents are often brief and may forget details that are important to mention. So be more meaningful than your resident in your notes without writing a book a day.

You now fully understand my step by step guide on how to write med school notes. Now you can write your progress notes quickly and without stress.

This process is also beneficial because interviews with your patients will be much faster and more focused. You don't go into your patient's room and ask for x, y, and z, they don't matter. A prepared note will structure your interview. Your interactions with your patients will not only be more focused, but they will feel like they know what to ask.

Once you've completed your interview, it's as simple as entering your information.

Using the above approach, I was praised for the quality of my notes. Now you can do the same!

So that was the step-by-step approach I use every day to write med school notes. This not only prevents me from arriving early, but also from leaving late. I hope you can use these tools to make your morning rounds and H&Ps easier.

If you liked this post, take a look at the following posts:

How to Skillfully Present Patients in Medical CollegeHow to build strong relationships with your patientsThe Power of False Confidence: Overcoming Impostor SyndromeRegain motivation in medical school
How do you take notes for med school? [Step by Step]

If you would like me to cover something specific in a future blog post, please comment below or email me at[email protected]

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Until next time…