Bruce Peyser, MD, FACP
Provider, Duke Primary Care Pickett Road
Professor of Medicine, Duke University School of Medicine
Director of Education and Teaching, Duke Primary and Urgent Care
In late summer 2018, our health system released a template that students and providers could collectively use to document patient interactions in the outpatient setting. The goal was to provide a way that medical students could become more involved in the care, management, and documentation of these interactions.
Anyone who has listened to Coach Mike Krzyzewski analyzes a basketball game has heard him refer to certain players, or shots, or points that became “game changers” and resulted in a subsequent win or loss. For students and providers who have started using this documentation template, it has become obvious the template has the potential to become a “game-changer” in our outpatient world.
Many students have wanted to practice note writing in preparation for their future careers in medicine, and many resorted to composing their notes in a Word document. What happened to these notes varied, dependent upon the student and teacher. Some notes were read and critiqued, some were copied and pasted in the provider’s note (something that actually violated guidelines for provider note writing), and some were probably ignored or not read in much depth.
With the advent of the new template, and with the blessing of our health system compliance team, many of us found we could adopt the note-writing template to our individual needs and preferences. It was not a surprise that our students quickly adapted to the process, and their skill sets improved rapidly. It was a big help to have students write some of the notes, and this resulted in a bit more time when we could examine a patient together and talk about the assessment and plan.
One of my third-year medical students, Charlton Tsai, eloquently summarized his experience with note writing.
“From a student angle, writing notes has been helpful in the sense that, much like an oral presentation, it allows me to practice articulating the patient’s story and formulating an assessment and plan in a clear, coherent, and concise manner. It can reveal weaknesses in my data-gathering skills when I realize I missed a portion of the HPI or the physical exam. It allows preceptors to give better feedback on my work. And it provides a sense of satisfaction when I see that my preceptor has utilized my note with minimal addendums.”
Note writing takes time (as we all know so well), and it extends the amount of time a student spends with a particular patient and the medical record. For a half-day in the clinic, it seems as if the documentation of three notes is a sweet spot that balances achievement of the skill set while allowing for some other patient interactions the provider can document. For now, I would urge you to limit the student note writing to two to three notes per session, and not more.
Again, from Charlton: “The only real downside with note writing is that I see fewer patients when writing notes, and using the computer in the patient room can be disruptive to rapport building. But I would counter that with the fact that when you write notes, you think more deeply about each patient’s case, and that learning how to engage a patient using a computer is a vital skill for the modern physician. I do think notes become less useful when 1) the preceptor does not provide feedback and/or 2) the preceptor does not review the note and thus ends up duplicating a great deal of work when writing their own notes.”
If you work with medical students and have not tried this new process, I urge you to give it a try. It might enhance your workflow and possibly result in a better note and less exhaustion at the day’s end. Also, I urge you to make time at the end of the session to meet with your student to debrief the day, the interactions, and the notes. Remember: You cannot ever give too much feedback!
One last item: At this juncture, the Centers for Medicare and Medicaid Services has indicated nurse practitioner and physician assistant students are not able to participate in this note-writing process. This means they cannot work on notes that you adapt as yours. Also, NP and PA preceptors cannot use notes written by any student as part of their workflow. There are petitions in place to change this process and hopefully, within the next year, all students and all providers will be able to collaborate on note writing. They can and should still practice writing notes that can be done in a Word document, but we need to be careful not to cut and paste that work into our individual notes.