Make your notes more readable: three tips from a nocturnist for minimalist medical documentation

From a great talk by nocturnist Dr. Mo during orientation—one of the reasons why we in medicine write notes is to communicate important information to colleagues, and now, to our patients. However, many notes are a pain to read because they contain too much irrelevant information, are poorly formatted, or do not show the thought process of the author. Here’s Dr. Mo’s talk broken down and viewed from a minimalist’s perspective:

  • Simple: Example: “John Doe is a 35-year old man who presents for confusion. History is given by wife. Patient was difficult to arouse this morning, appears tired, complains of generalized abdominal pain, and has vomited twice. She is unsure whether patient took insulin last night after patient ate cake to celebrate daughter’s birthday. Past medical history includes type 1 diabetes mellitus, chronic kidney disease.” Why is the patient presenting? Don’t overwhelm your reader with a laundry list of irrelevant chronic conditions. Save John’s likely unrelated hypertension, hyperlipidemia, migraines, anxiety, and depression for the problem list.
  • Organized: Blocks of text may be difficult to read, especially for tired eyes that have been staring at blue screens for the last 11 hours. Break up your paragraphs into blocks separated by spaces after, say, 2-4 lines. Find what works for you. Ask others for feedback.
  • Explanatory: Show that you understand the pathophysiology or diagnostic criteria in a way that is clear and concise. The problem-based assessment and plan for John may look something like this:
    • “Glucose 650 + pH 7.2 + high beta-hydroxybutyrate” (indicating hyperglycemia + acidosis + increased ketones)
    • Fluids (specify type and dosing)
    • Insulin (specify type and dosing)
    • Potassium (specify dosing)
    • Etc

I’d like to thank Dr. Mo for providing the lecture on which this post was built. What do you think? How else can you make your notes more straightforward and readable?

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