All the third-year medical students were paired up. Debbi and I were happy to be working together. We had become good friends in the past two years. Debbi had managed to survive the grueling academic schedule despite a 90-minute commute each way, despite caring for a child while pregnant with her second. She delivered her second son during the summer break, then nursed him while sitting through third year classes. Some of our classmates had no appreciation for what she was going through.
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Once during second year, the tape for note service came out inaudible. The person responsible for note service that day tried to get Debbi to give up her personal tape of the lecture. Listening to tapes while driving was how she managed to stay afloat. Our classmate was asking her to give up her life jacket. When she refused, he tried to guilt her into it by saying it was for “the good of the class.” (more…)
There has always been a disconnect for practitioners between doing what they do and then writing about it in the patient’s chart. This was true when we had paper charts, and the advent of EHR (electronic health records) has made the separation even wider. When my notes were on paper, written longhand, I often got compliments from other practitioners. They found my notes to be clear, concise, and helpful in orienting them to what my plan was, and to what was going on with the patient.
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Paper Versus Electronic Note
E-notes tend to be long because they’re inclusive. Prior history, problem list, vital signs, fluid intake, labs, x-ray reports, medication lists can all easily be pulled into a note. This is precisely what makes them so unfocused and useless for emphasizing what the note writer thinks is really important. (more…)