On a busy ward or intensive care unit rotation, new physicians beginning their intern years quickly realize that staying organized and balancing large patient loads with bedside patient care, preparing for rounds, signing notes/orders, and completing tasks can be difficult.
Early in my intern year, I spent some time creating a structured progress note template in the electronic health record with smart phrases that automatically pulled vital signs, ventilator settings, medications, lab trends, ins/outs, invasive lines, the results of diagnostic studies, etc.
Each morning before rounds, I’d start a progress note on each patient, copy it into a Word document, resize the document to fit on one page, and print it. This would be my “scutsheet” on rotations where I couldn’t round with a computer. When I went to examine the patient, I would update relevant items in my note.
During rounds, I never had to worry about missing any information as the objective findings would already be pre-populated on my scutsheet. Because I had one page dedicated to each patient, I would fold the paper in half and use a checkbox system for tasks that needed to get done for that patient.
For example:
- [ ] consult nephrology
- [ ] f/u CXR
- [ ] f/u PM BMP
- [ ] f/u home health with case manager
The majority of my post-rounding activities involved procedures, adjusting orders, and following up with consultants. This routine maximized my efficiency, but I couldn’t do it without scutsheets (and checkboxes!) to keep my plans, lab values, vitals, and daily progress notes organized!
Do you have a copy of the template you made for yourself?
Unfortunately, I don’t! My days as a trainee were spent on Epic. Now I’m on Cerner.