How to Write Better Progress Notes
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- Опубліковано 11 лют 2021
- My 10 tips for writing better progress notes in the hospital to improve communication, efficiency, and patient care!
0:46 Make your notes beautiful (aka eliminate note bloat and make it obvious where a human is writing)
2:38 Hide unnecessary data
3:30 Write a real assessment
4:45 Write a real disposition
6:01 Use size 10 font
7:10 Shorten the physical exam
8:07 Find useful smartphrases
9:22 Use a hospital bundle
9:41 Add built-in reminders
10:41 Document in the actual EMR
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Guides for medical students: • Medical School Guides
Guides for residents/interns: • Residency Guides
Guides for using Epic: • Epic EMR Guides
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man, i love people who become successful at what they do then share their knowledge freely for everyone. you did it with starcraft, and now you're doing it with medicine! nice!
Hey Doc! MS3 here. I would love to see your process of creating these templates start-to-finish. Would love more EPIC content :)
Thanks!
Thank you, Dr. Liu!! SO HELPFUL.
Thank you ohnolillam!
Great videos. Maybe one on reviewing questions? Not sure if you remember. I’m suffering from step 1 studying now. Hope to call you a colleague one day!
my adhd brain thanks you for this
This is so helpful for a new Physician Assistant. So helpful. Can you make a video like this for outpatient too?
Thanks for your suggestion :) definitely will try to do that at some point in the next month or so!
As a fellow PGY1, found this super helpful! Wish our EMR had the ability to auto-collapse the Objective section. Have you ever gotten pushback from attendings that your physical exam doesn't have 12 points/organ systems in it? I was told once they needed that for billing purposes...
If you look for it you may be able to find collapsible sections - I had to explore smartphrases to find that. Never gotten anything about the physical exam even from the coding department which is why I recently decided to change it. California law recently changed to not requiring excess physical exam points (don't even have to put physical exam if nothing was relevant) which is when I decided to change it, but I still want to go over with the billing department what exactly is required for notes. I've been messaging them just waiting for a response
high-yield!
omgggg nOtE bLOat is awful!!!! >:( and also 100% yes love the aesthetic approach, and how you auto-hide the objective data - makes a lot of sense workflow-wise ---> rest of the tips are excellent as well; ty conan! (and thanks for marking the dif parts of the video for easy navigation :)
Hi Conan, Thank you for all your videos. I am from Canada, I think we use similar EMR system. I was trying to personiliaze your progress note templete on Epic. I could not find you in the system. is there anyother way to use your templetes . Thank you
Each hospital system has different templates, so you'll have to try to develop it on your own with your institution's tools! The most helpful thing to type (if you are using Epic) is .? and it will bring up a list of all the available system smartphrases
Thank you for your reply. @@ConanLiuMD
Hey great vid. We use epic too but I cannot find a smartlink for the LDA and last BM link that always updates. Please help!
It will be institution dependent - it can be kind of hard to find this stuff unfortunately, you'd have to ask someone at your institution or play around until you potentially find something :(
What are the dot phrases!!! Your video should detail how to do them & how to save your most frequently used entries
Not exactly the same, but I found this helpful: ua-cam.com/video/EP7M4dTebww/v-deo.html
what is the smartphrase for last BM? thanks!
depends on your Epic! It usually is under .flowsheet but you have to find the individual value
@@ConanLiuMD ok cool. at your institution what is the actual ".flowsheet" smartlink? thanks
Do you have a vid helping to write up the plan? Sometimes I struggle compiling all the objective info into a statement phrase. Such as instead of saying 'Pt was found to have elevated BNP', I would say patient presented in decompensated HF. I'm trying to eliminate 'note bloat' like you said and incorporate the objective data in a more 'reader friendly version'. I'm big on using bullet points bec. I cannot read long paragraphs but I also want to get my thoughts across without it being too vague or too wordy.
I think it's a continual improvement process! It's still something I'm working on as well. You want to be concise (so your note is actually legible) but clear and thorough so that it includes all the necessary information someone might want to know. It's a tough balance - like I said I'm still working on it daily as well. Maybe eventually I will try to make a video on my approach to it. A lot of it is stylistic though, and it's definitely normal to feel like you aren't sure what kind of info to include at first! I think we will get better with time though :)