In the era of electronic health records (EHRs), writing progress notes (PN) has become largely supplemented by auto-populated fields (labs, radiology, medical history, etc.) and information which has been copied from prior exams and/or other notes. PNs are a centralized form of communication to other healthcare providers regarding your treatment team’s clinical assessment and plan. Here are some tips to write short but effective PNs in the EHR.
Become familiar with templates/smartphrases in your EHR. These can save valuable time, but be wary of abusing auto-populated fields. I use templates to structure my overall PN with headers (last 24 hours, objective data, assessment, plan by organ system) and have a few smartphrases to autopopulate recent vital signs, intake/output, etc. Do not overburden your note with autopopulated text.
Every order (medication, restraint, lab check frequency, etc.) should have a justification included in the system/problem-based plan. This helps everyone reading the note understand the rationale for certain clinical decisions.
SYNTHESIZE AND INTERPRET
There’s no need to have pages of labs, microbiology data, medications, procedure reports and radiology reports fill your PN. I have a low threshold to, for example, “Labs reviewed, relevant findings include Hb 8.8 -> 9.2, platelets 144K -> 198K, WBC 4.8 -> 12.4, K+ 3.2, and creatinine stable at ~1.2.” This takes up one line in my note and substitutes massive lab tables which become cumbersome to read. I do the same for all the objective data.
It’s important for you to read and actually process the findings rather than copying the report impressions.
I always have a running hospital course in my PN and add significant events (code blue, septic shock, major procedures, family meetings, intubation, renal replacement therapy, etc) each day. This makes writing transfer notes a breeze!
In the ICU setting, I structure my clinical plan for each system. I try to emphasize writing a diagnosis with a plan afterwards. Additionally, use ACTUAL dates instead of terms like “today” and “last week.” This is especially important for antibiotics (where you also want to include duration of therapy). Here are some systems-based examples:
- Analgesia: acetaminophen 1000 mg PO q6h, gabapentin 300 mg PO TID, toradol 15 mg IV q6h, fentanyl 25 mcg IV q1h PRN for breakthrough
- Insomnia: melatonin 3 mg qHS, quetiapine 12.5 mg qHS
- AFib: rate controlled on metoprolol 5 mg IV q4h, heparin drip for now
- HTN: valsartan 80 mg daily
- CHF exacerbation: BNP > 9000 on admission, diuresing well on Lasix drip (3-5 mg/hr, goal net negative 500-1000 cc daily), TTE with LVEF ~40%, no valve issues, increased filling pressures, and PAP WNL
- Hypoxemia: on low flow nasal cannula, wean as tolerated, CXR with no overt consolidations
- Bronchospasm: Duonebs q4h scheduled
- DM2: holding metformin, continue 10 units NPH BID and regular SSI. qAC/qHS BG
- RA: continue prednisone 5 mg daily
- Septic shock: Resolved: 9/5 BCx, UCx, BAL, and wound cultures with NGTD. Empiric coverage with Zosyn (9/5 – now) and vancomycin (9/5 – now). Appreciate recommendations from ID.
Drop me a line in the comments section below if you have more questions! 🙂