Writing a Note
As a clinical clerk, you will be writing notes everyday. It could be an admission note, a progress note, a consultation even a discharge summary. Either way, learning how to write a useful note is key skill.
Writing any note is not hard, writing a good note takes some effort and writing a bad note is all too easy.
In part 1, I will outline the basic essentials you should know when you write a note. All these tips have nothing to do with content and everything to do with process. A lot of it will seem like common sense, but you will be surprised as to how often people lack it. By making sure you have these elements, you’ll make sure your writing can be useful. Be sure to check out Part 2 too!
1. Write the Date and Time
As simple as it sounds, writing the date and time is super important. Remember, that everything that you write in your patient’s chart is part of a legal document. Making sure you date and time all your documentation is a habit you should ALWAYS practice.
Aside from the legal aspects, you have to remember that this chart will be accessed by multiple people at different times. It’s helpful to know which medical orders were written first and similarly when did consultants come to see your patient.
The first thing you should write should always be the date and time. If you’re in a rush, try to at least remember the date!
2. Identify Yourself
You should always identify which service you are from and what’s your role. For example, a progress note may start with a header like this – Internal Medicine CTU A – Clinical Clerk Yr 3 Progress Note. Now anyone who picks up the chart can easily know who wrote in it. You’ll see the RN/OT/PT/SW and other health services do the same.
Don’t expect other people to recognize your writing, write down who are you!
3. Write Legibly
There’s no point in writing down information for other people if they can’t read it because it’s messy. If you know you have messy handwriting, take your time and print. Type your notes on a computer if necessary.
Illegible handwriting is dangerous!
Especially if you’re prescribing a new medication, drugs have similar sounding names or dosages may be read incorrectly. I know doctor’s get a pretty bad rep for messy writing, and rightly so. There are no excuses. If your writing looks like chicken scratch – either learn how to write neater or slow down so you can print legibly. Write neatly and legibly.
4. Write with Black or Blue Ink
Always use a pen. Pencils are big no-no’s. Similarly, use dark colored ink like black or blue, they show up much better in faxes and photocopies. Colors like red and green are frowned upon. Often nurses and unit clerks use those colors to differentiate their writing from yours.
5. Press down hard enough for carbon copies
A lot of documents like orders, consults and discharges will come with carbon copies attached to it. Make sure you push hard enough with your pen so that your writing is actually copied onto the sheet below. Ballpoint pens do the trick well. If you’re using gel or fountain pens, make sure to press down a bit harder.
The last thing you want to do is retrace everything you wrote to actually get a copy.
6. Sign Your Notes (Properly)
You should get into a habit of signing everything you write with your signature, printed name/role, and contact information if necessary.
Putting your signature down is like your stamp of approval. It authenticates that you have written/read/reviewed this note and you approve of it. Sometimes you’ll find residents and staff co-signing your note, which states that they “approve” of it.
Likewise, put your name and title with your signature. “John Doe – R2 +/- you’re service” is all you need.
Contact information can be useful, especially with consultations or if you’re leaving a note for a different service. Writing down your pager number is a good idea on orders also. If your name is legible and you have your contact information down, people can easily reach you to clarify any misunderstandings.
7. Get Co-Signs if Needed
At a lot of schools, orders and certain documents like Code Status (DNR) and discharge summaries need a resident or attending physician signature. Prescriptions will also require co-signs.
Co-signs are a way to ensure orders are “proof-read” before they can be initiated. Sometimes they can be quite a hassle, especially if no one is around to sign them. My advice would be to batch them together so you can get co-signs all at once, or to let your resident/staff know about them early so they can anticipate when they need to sign stuff.
In conclusion for Part 1, I’ve talked essential elements you should include with every note you write as medical student clerk. A lot of it is common sense that often is forgotten.
So remember the main points, (1) Write the Date (2) Identify Yourself (3) Write Legibly (4) Sign your documents. Actually, even if you can remember to do #1 and #3 for the rest of your clerkship year, it would make a big difference for anyone reading your notes.
Part 2: In this next part, I’ll be talking about the content of writing a good note and how do you go about writing a note that is organized and useful for other health care workers.
Do you have any additional things you always write with your notes? Anything that is omitted that drives you crazy? Feel free to share in the comments below!