With all of the attention placed upon Coach K this past week, I have been contemplating some of the “game-changing” events that have affected us in our outpatient world. I certainly think that the rule changes that have allowed learners to help write notes would fit into this category. I wanted to review some of the important guidelines that pertain to note writing and share some tips that will result in a valuable written record of an office visit.
When I have a new learner with me, I have them focus initially on demonstrating that they can obtain a good history and perform a solid physical examination. Sometimes this happens right away, and other times it can take weeks of practice before a learner is ready to start writing notes. When they do finally begin to write a note, I only have them do one or two in a half-day session. Towards the end of a rotation, I might have them write three notes, but never more because then they feel more like scribes and have less time to talk with patients or read about them after the session is over.
All students who are involved in note writing need to use a template that has been created and can be accessed when the following is typed:
.studentandsupervisorattestion. This is in a standard SOAP note format, but there are two key critical components at the end which is a student attestation and a supervisor attestation. It is critically important that student-composed notes contain these attestations at the end so that we can document how the note was created and what we might have added or adjusted within the note.
At the end of the day when I sign all of my notes, I review the student’s note and then I will add some additional verbiage usually confirming the most important features of the history or the assessment/plan. This way the person reviewing the note will understand that I properly saw and evaluated the patient, and was integral in the creation of a safe and proper treatment plan.
I am going to bet that it will NOT surprise you to learn that Duke has created a simple eight-page Tip Sheet that reviews this and other important aspects of how we should be documenting our work and billing properly when working with learners. You can access that tip sheet here……. And if you want to learn even more, you can watch and listen to a helpful presentation within our learning management system that reviews a variety of ways that notes can be co-authored. Here is a link for that presentation and I urge everyone to look at this if you have not already done so…………
Also, it’s important to give students feedback about their notes. Sometimes I do that right when they are in the clinic, and sometimes I will wait until later in the day or evening. But in any case, know that the students want to hear what you think of their notes, and universally, they want to improve so that they can compose notes that will be useful to you and to the health system.
I suspect that many of you can relate to the fact that having students help with note-writing results in a different workflow than what you were previously probably used to. I would urge you to try to be patient and adapt to the change and accept the fact that this might disrupt your workflow. With some modest attention to detail and provision of feedback, I find that most students can and do write notes that often are better than my own. So give them a chance, and let them become the real “game changers” in your office!
Finally talk about giving feedback
Different work flow