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.


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]

As always please like, share and subscribe. enroll inmy monthly newsletterto receive updates on new blog posts. If you register you will also have access to my free eBook,Top Ten Resources for Medical School. RecordHere!

Step-by-step guide to writing medical school notes - TheMDJourney (1)

If you are a first or second year medical student and want guidance on how to successfully complete medical school, please read my book.The preclinical guide.I'll give you all the advice you'll want to know on the first day of med school. look at the bookHere.

Step-by-step guide to writing medical school notes - TheMDJourney (2)

Until next time…


How do you write medical notes efficiently? ›

How to Take Notes Faster in Medical School
  1. Never copy verbatim. Have you ever copied text from the textbook and then struggled to remember it? ...
  2. Use abbreviations. Abbreviations are a good way to speed up writing. ...
  3. Try the outlining method. ...
  4. Use the mapping method. ...
  5. Try the Cornell method. ...
  6. Highlight text in different colors.
Mar 29, 2021

What is the best note taking method for medical school? ›

The outline method is one of the most common techniques used by Medical Students to take notes from lectures and turn them into something more useful in a way that encourages active learning. Many people like to use the outline method because it's clean and easy to use.

How do you organize medical school notes? ›

I usually use the draw functions to add arrows to radiographic images or to circle important points on slides. I usually organize my notes by subject but other students organize by date, with tabs for each block, each week within the block, and day of the week, and individual note pages for each lecture that day.

What is the most effective way to write notes? ›

If you want your notes to be concise and brief, use abbreviations and symbols. Write in bullets and phrases instead of complete sentences. This will help your mind and hand to stay fresh during class and will help you access things easier and quicker after class. It will also help you focus on the main concepts.

What is the best method when writing notes? ›

The outline method is one of the most intuitive and simplest ways to take notes. As the name suggests, the outline method turns notes into a hierarchy of information, providing a logical flow of content on the page and keeping it highly organized. With the outline method, you can take notes by hand or digitally.

What are the 4 note-taking strategies? ›

Use the four primary methods of note taking: lists, outlines, concept maps, and the Cornell method.

Which of the 3 methods of taking notes is most effective? ›

The Cornell note-taking method is one of the most popular and renowned note-taking techniques, created by Prof. Walter Pauk of Cornell University in the 1950s. It's designed to make you actively think about your notes as you go along, rather than mindlessly jotting things down.

What is the fastest way to memorize school notes? ›

Simple memory tips and tricks
  1. Try to understand the information first. Information that is organized and makes sense to you is easier to memorize. ...
  2. Link it. ...
  3. Sleep on it. ...
  4. Self-test. ...
  5. Use distributed practice. ...
  6. Write it out. ...
  7. Create meaningful groups. ...
  8. Use mnemonics.

What is the fastest way to memorize for medical school? ›

10 Doctor-prescribed tips for studying in medical school
  1. Review material regularly. ...
  2. Write it down. ...
  3. Test yourself. ...
  4. Create an effective learning environment. ...
  5. Improve memorization with mnemonics. ...
  6. Use visuals. ...
  7. Incorporate auditory methods. ...
  8. Consider forming a study group.
Aug 5, 2021

What is the fastest way to memorize medicine? ›

Spaced Repetition

Students can also make or purchase flashcards for self-testing. You can easily practice using this technique, which seems to enhance both memorization and skill acquisition, while you're in college.

How do you write school notes neatly? ›

Here are some tips on how to take good notes.
  1. Write down key facts. If you have a teacher who writes notes on the board, that's a bonus: You can copy them down. ...
  2. Don't overdo it. Don't go crazy taking notes, though: You'll be frantic if you try to write down every word that's said in class. ...
  3. Ask. ...
  4. Compare. ...
  5. Copy. ...
  6. Organize.

What are the five best notes to be considered when choosing a doctor? ›

5 Things to Consider When Choosing Your Doctor
  • Are they really in-network? ...
  • Is the doctor accepting new patients? ...
  • Can I book the appointments I need? ...
  • How far away is their office? ...
  • Do people like this doctor?
Nov 2, 2021

Should I make notes or flashcards? ›

If you want to learn a topic with a lot of stuff to memorize, flashcards will help you do it better than almost anything else. Mnemonics are trendy, but for medium-to-long-term purposes, flashcards are probably better. It's also easy to waste your time with flashcards.

What should one avoid while taking notes? ›

Everyday Note-taking Mistakes and How to Avoid Them
  • Scribbling down everything in a hurry. ...
  • Similar note-taking style for different courses. ...
  • Skipping the section, you don't understand. ...
  • Highlighting and underlining everything. ...
  • Never reviewing the notes. ...
  • Unorganized notes. ...
  • Not asking questions during lecture.
Feb 24, 2021

What are the two main methods for good note taking? ›

These particular methods are some of the more popular methods for taking notes.
  • The Outline Method. This method is used for simplicity and is one of the easiest methods of taking notes. ...
  • The Cornell Method. ...
  • Mind Mapping Method. ...
  • Flow Notes Method. ...
  • The Sentence Method. ...
  • Charting Method. ...
  • Writing on Slides.

How do you write neatly and fast notes? ›

Do you want to learn how to take efficient and neat notes while studying?
  1. Keep a separate notebook and use color codes. ...
  2. Use abbreviations and symbols. ...
  3. Effective and neat notes: Start sentences. ...
  4. Using diagrams when taking notes. ...
  5. Highlight different aspects of your notes using highlighter. ...
  6. Effective use of Post-it notes.

What are the 7 rules for note-taking? ›

Techniques and Tips for Listening and Note Taking
  • Write phrases, not full sentences. ...
  • Take notes in your own words. ...
  • Structure your notes with headings, subheadings and numbered lists. ...
  • Code your notes—use colour and symbols to mark structure and emphasis.
  • Use colour to highlight major sections, main points and diagrams.
Mar 25, 2022

What is the most important part of the note-taking process? ›

Review and edit your notes. Academic skills centers and other authorities on effective study skills consider reviewing and editing class notes to be the most important part of note-taking and essential to increasing learning capacity. It is extremely important to review your notes within 24 hours.

What are the 5 R's of note making? ›

This format provides the perfect opportunity for following through with the 5 R's of note-taking:
  • Record. During the lecture, record in the main column as many meaningful facts and ideas as you can. ...
  • Reduce. As soon after as possible, summarize these facts and ideas concisely in the Cue Column. ...
  • Recite. ...
  • Reflect. ...
  • Review.

What are note-taking key words? ›

What Are Keywords? Keywords are words that convey more than just the meaning of the word itself, within the context of a set of notes or a set of information. Sometimes they are also called keyphrases (as often they'll be 2-3 words in a phrase) or trigger words.

What are the five steps to focus notes? ›

Select a note-taking format, set up the note page, record the Essential Question, and take notes based on an information source (lecture, book, website, article, video, etc.), selecting, paraphrasing, and arranging information in a way that meets your note-taking objective.

What is the best page layout for note-taking? ›

First, the page should be divided into two columns: the left one taking around 30% of the paper and the right one taking around 70%. Second, there should be space at the bottom of the page for the Summary. When using this method, write all notes in the right column.

What are the 4 types of notes? ›

We're going to learn four types of notes and rests; whole, half, quarter and eighth.

How do you outline notes? ›

Learn the outline note-taking method in 5 easy steps
  1. Step 1: Define the main topics. The first step is to outline the critical points of the material. ...
  2. Step 2: Identify the subtopics. ...
  3. Step 3: Add in evidence and supporting material. ...
  4. Step 4: Provide examples and further details. ...
  5. Step 5: Review and revise your notes.
May 2, 2022

What is the charting method? ›

The Charting method

This method involves using a table to make your notes. You can have separate columns for main points, questions, details etc. This method pretty much involves you classifying your information so you can easily access it.

How do you take notes like a pro? ›

Select a style of note taking and stick to that style. Consistency is key; using the same style over and over makes it easier for you to find information in your notes. That means that your notes will be more useful to study from. At the beginning of class, write the date and topic at the top of the paper.

What are the 3 R's of memory? ›

To study effectively remember the 3Rs: reading or looking at charts, maps, web sites, etc; recording or taking notes to help you remember what you have read; and reviewing, or going over your notes so you will remember the information you have learned.

How to learn big answers in 5 minutes? ›

  1. Read the whole answer only to understand.
  2. Don't think of memorizing in one go.
  3. Break the question in parts( as many u wish.. ...
  4. Now go through one part and learn it loudly.
  5. Now check whether u have learned by hiding the answer.
  6. If yes: repeat processes 4 and 5 till u complete the answer.

Why can't I memorize my notes? ›

Major memory changes don't always signal Alzheimer's disease. They can be caused by strokes, head injuries, lack of vitamins in your diet, or sleep trouble. They might even be a side effect of one of the drugs you're taking. When in doubt, see a doctor to sort it out.

What are the hardest years of medical school? ›

Year one is the hardest year of medical school.

Many students will likely disagree, but the first year is widely recognized as being the most difficult. The majority of the first year of medical school is spent in classrooms and labs and requires an enormous amount of memorization.

What is the average IQ of a doctor? ›

The average I.Q. of a doctor is approximately 125. Studies have determined that a doctor's I.Q. will normally fall within the 110-130 range, putting them into the 'high average' and 'superior' Wechsler classifications.

Are the first 2 years of medical school the hardest? ›

According to NRMP and other online sources, the hardest year of medical school is first year. Year one of medical school is the most difficult for many reasons. Some of these reasons include: moving to a new location.

Which branch of medicine is the easiest? ›

Photobiology, dermatopathology and allergic disorders are just a few. You could even go for aesthetic medicine which opens up a whole new avenue. One of the best things about it is that there are not as many cases of serious patient illness, or fatalities. But again, dermatology requires no less effort.

How do I not forget what I studied in medical school? ›

Use Spaced Repetition

By reviewing information multiple times, we are less likely to forget it over time. This repeated review and recall cycle works best if each review is spaced out in time, rather than reviewing the same information multiple times in quick succession (Karpicke & Bauernschmidt).

How do med students memorize so much information? ›

Taking Practice Tests

According to several studies, self-testing is a proven technique that helps medical students to retrieve information and better memorize what they have learned. Taking practice tests is a retrieval practice that boosts long-term memory of medical students.

How can I make my notes better? ›

How to Take Effective Notes
  1. Take good notes.
  2. Organize your notes.
  3. Format your notes by labeling them.
  4. Listen for main ideas during the lecture.
  5. Find vocabulary words.
  6. Use abbreviations.
  7. Condense your notes.
  8. Use a note taking system.

How can I get a realistic doctor's note? ›

What Should be Included in a Doctor Excuse Note?
  1. Title: The document should have a title that looks official. ...
  2. Doctor/Medical Facility Information: ...
  3. Date of Document: ...
  4. Patient Information: ...
  5. Purpose of Appointment: ...
  6. Certification of Condition: ...
  7. What is Being Authorized: ...
  8. Signature:

What makes a good clinical note? ›

They should include: 1) All relevant clinical findings. 2) A record of the decisions made and actions agreed as well as the identity of who made the decisions and agreed the actions. 3) A record of the information given to patients. 4) A record of any drugs prescribed or other investigations or treatments performed.

Are doctors notes hard to get? ›

Getting a doctor's note for work is a simple process. When you visit your physician or clinic, simply let them know that you will need a doctor's note to provide to your organization.

What is the best note-taking method for medical school? ›

The outline method is one of the most common techniques used by Medical Students to take notes from lectures and turn them into something more useful in a way that encourages active learning. Many people like to use the outline method because it's clean and easy to use.

Which notes are better handwritten or printed? ›

A study found students who wrote notes performed better on tests than those that typed. If you want to learn better, handwriting your notes is the way to go. It leads to better memory, stronger conceptual learning and comprehension. In short, there is more cognitive processing with hand writing.

What is the best way to write flashcards? ›

The most effective flashcards include one question followed by one answer (or one term followed by one definition). Don't force your brain to remember a complex and wordy answer. It's easier for your brain to process simpler information so split up your longer questions into smaller, simpler ones.

How do I get better at medical documentation? ›

5 tips to improve clinical documentation
  1. Define professional standards. ...
  2. Expand education. ...
  3. Create peer-to-peer support systems. ...
  4. Review information. ...
  5. Allow patients greater access to EHRs.
Jan 22, 2015

What are the three C's of accurate documentation? ›

3 C's of Accurate Documentation
  • Be Clear. The first step in any problem solving is identifying the problem and writing it down as a problem statement. ...
  • Be Concise. Note-taking while listening and speaking to someone on the phone may mean writing in phrases. ...
  • Be Complete.
Sep 3, 2013

What are the 10 C's of professional documentation? ›

writing or presentation, namely, clear, complete, concise, considerate, correct, creative, credible, current, and more.


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