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Are Your Progress Notes Understandable?

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“I read in the note that they noticed some redness around the surgery site?” the patient’s granddaughter asked me. It was late in the evening, near the end of visiting hours. I was on call for the weekend when I was paged by the nurse, who told me that the family wanted to speak to someone regarding their grandmother’s health. 

At first, I was surprised. The chief resident and I did notice increased erythema around the incision on rounds that morning, and I had dutifully recorded it on my exam for the day: “Ex lap incision approximated with staples and with new surrounding erythema without purulent drainage.” I knew that patients could now access their progress notes, but I had never heard of a resident being asked to discuss the contents with them and their family.  

I like to think that I’m decent at writing progress notes. I had started off my medical career as a scribe, back when scribing was starting to pick up traction in the medical industry. I worked in a busy dermatology office, where I wrote nearly 40 progress notes a day. When maintaining the note was my only job, I was able to be particular and diligent about the specifics of its content. Now, as a resident, I realize how easy it is to put the progress note on the back burner. Patient care, daily orders, and the other numerous tasks with caring for my patients meant the progress note became another tedious item on the to-do list. It’s easy to treat it like a burden. But since that call shift with the patient and her granddaughter, I’ve been trying to remind myself of the understated value of the progress note. 

I readily admit that one of my personal draws to surgery was how succinct their progress notes were. I also readily admit that these notes can be particularly minimalist and can look like a checklist. But my speciality isn’t the only one with its bad habits. I can scroll through a patient’s medical record and find a field of note-writing sins. I’ve seen medical student notes where detailed hospital courses are left in the body of the assessment and plan, without any editing from the cosigner. I’ve seen attending notes where broad and vague dot phrases are used in place of describing specific interventions. And I’ve seen clinician notes from all levels of training with exams that are copied from the previous day without any updating; rashes that have resolved and tubes that have long been removed still exist on the patient’s virtual body days after. 

As an intern on the steepest part of the residency learning curve, I commiserate with how easy it is to succumb to administrative shortcuts when there are 18 patients to care for and you’re the only one on the floor. As a scribe, my only true responsibility was the note. But as a resident, my responsibility encompasses my patients and my duty to the other clinicians I work with. I have come to appreciate how a well-maintained note is key for teamwork, and therefore needs to be functional and intentional with its content. When I read others’ notes, I can’t help but wonder what exactly their team has done since their last note, what their clinical reasoning was, what conversations they had with the patient and family. I have also reflected if others can glean that from my notes: Does the reader understand my team’s thought process? Are they fully looped in on our plans for this patient? 

I realize that, despite my previous career, my progress notes are a work in progress. My patient and her granddaughter served as a reminder that, as clinicians, we should be intentional about the content we include. Like surgical scars and hospital bills, progress notes are permanent proof of the care we provided to another person. They’re a tool for interdisciplinary teamwork, and a source of information for the families that read them. We should take the time to appropriately update the note, even if we only have two minutes to spare. As I adjust to the role of a resident, I want to challenge myself and my peers to think of the progress note not as a perfunctory task, but a prudent one.

What approach do you take when writing progress notes? Share your strategies in the comment section.

A Texas native and Massachusetts transplant, Dallas Walter is a general surgery intern at the University of Massachusetts. Her personal interests include social disparities of health, diversity in medicine, and stand-up comedy. Dallas is a 2021–2022 Doximity Op-Med Fellow.

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