Communication is pivotal part of any job, especially in the medical field. Face to face communication is the conspicuous example in healthcare. However, writing is the form of communication that allows healthcare to flourish. From patient care reports and physician addendums to research consent forms, and discharge papers there is a plethora of paperwork and legal documentation. With this vast amount of writing there is no room for mediocre writing or communication. Ineffective writing could potentially lead to patient harm or even death. With patients’ lives at stakes, the necessity for efficient writing skills is a paramount in the field of medicine.
When most people go to the doctor or the hospital, they just think about talking to their doctor and finding a treatment for their issue. What they don’t realize is that all the information they tell their doctor will later be written down and archived. As technology perpetually becomes more embedded into society, the use of digital documentation in the medical field has also become more predominant. Obsolete paper documents are now computerized in the electronic medical record (EMR). This change resulted in much more time behind computer screens for doctors. In one study focused on residents, 67.9% of residents spent an excess of 4 hours a day writing (Oxentenko). As an intern in Stony Brook Medicine’s Emergency Department, I have witnessed this firsthand. Majority of the time doctors are writing up reports as they sit at their desks. Unfortunately, the increased amount of documentation often impedes direct patient-doctor communication. Furthermore, as doctors become more pressed for time, the doctor’s notes they write consequently suffer. Instead of writing a complete document about their patient, some doctors will copy and paste information from older physician notes to save time (Chen). Surely this extremely dangerous for patient care.
The doctor’s note is a unique form of writing. It’s intended to be a personal narrative of a patient’s medical history, current symptoms, and planned treatment. There is a certain art to writing a doctor’s note than few learn until they’re actually forced to write one. I’ve had extensive experience reading through doctors’ notes as part of my internship. Each doctor has their unique style of scripting their notes. Some write in a casual tone, while others will bluntly list out the requirements of a successful doctor’s note. Some can be half a page long, while others will concisely hit all the key points in a few sentences. Most of the time these notes will be mostly abbreviations and acronyms instead of common words and sentences. As I first started reading physician notes, I was forced to google most abbreviations as a had no clue what they were referring to. I assumed that prospective doctors would learn these abbreviations in either medical school or during their residency.
There appears to be a lot of flexibility in the manner a physician note is written. Sometimes this flexibility can result in poorly constructed notes, however. How can this be avoided? In 1970 Dr. Lawrence Weed designed the SOAP system for physicians to follow when writing in the medical record. Today the SOAP system is used among a wide variety of health professions to document patient treatment. There are four parts to a SOAP note: subjective, objective, assessment, and plan. Subjective refers to the patient’s current symptoms and condition, including the chief complaint. The objective section contains the patient’s vital signs, lab results, and findings from any physical examinations. Assessment contains the doctor’s diagnosis for the patient, and the plan section entails the intended course of treatment (EMRSOAP). The SOAP system serves as a framework for healthcare professionals to accurately document their patient’s health status.
Although the SOAP system provides a clear guideline of what to include in a physician note, it does not guarantee that the note will be of high quality. For example, SOAP only demonstrated what information should be included, not the context or stylistic manner of the note. Each patient is unique and so should every note. Practice makes perfect, and this is certainly the case for writing a good physician note. An attending physician can rapidly script multiple high quality notes, while a new resident may struggle for hours with a single note. According to Dr. Thomas Robey, “…when it comes to the medical record, the best physician documentarians are great storytellers” (Robey). Robey divulges that he keeps a log of every single patient he encounters. This log helps him develop his patient storytelling skills. In addition, while the EMR may seem mundane, his log helps him feel personally connected to every patient he sees. It gives character to each patient, instead of generalizing all patients and losing track of who’s who. Every week, Robey reflects on his experiences with patients, and builds upon his original story form his log (Robey). This helps him ultimately become a better note writer. He continues to augment his ability to tells each patient’s exclusive story.
Writing a successful doctor’s not is a skill that takes time and practice to master. The SOAP system certainly provides some structure for physicians to follow, but that’s not enough to script a good not. Understanding medical terminology, obtaining the patient’s full story, and adding style to the note are just some of the additionally components required. There is an overwhelming amount of terminology and abbreviations writhing medical writing. Over 100 of these abbreviations can be found and explained in a document created by Ros Jones (Jones). This list was created to help patients understand some of the terminology their medical paperwork may contain.
“The most important skill in medicine is the ability to communicate” (Pollak). A physician note is a key example of how important communication is. Superficially, a doctor’s not may seem like a simple synopsis of a patient’s medical profile. But it is so much more than just that. To write a complete note, a physician must first obtain the entire story from the patient. This requires compassionate communication skills. Then, the physician must be able to portray this information in writing. The physician note is a unique form of writing that takes extensive time and practice to master.
Sources
Admin. “SOAP Notes.” EHR EMR Consulting Services, EHR EMR Consulting Services, 17 Jan. 2013, www.emrsoap.com/definitions/soap/.
Chen, Pauline W. “Doctors and Patients, Lost in Paperwork.” The New York Times, The New York Times, 7 Apr. 2010, www.nytimes.com/2010/04/08/health/08chen.html.
Jones, Ros. “Abbreviations | Doctor.” Doctor | Patient, Patient.info, 19 July 2012, patient.info/doctor/abbreviations.
Oxentenko, Amy S. “Time Spent on Clinical Documentation.” Archives of Internal Medicine, American Medical Association, 22 Feb. 2010, jamanetwork.com/journals/jamainternalmedicine/fullarticle/774409.
Pollak, Kathryn. “The Most Important Skill in Medicine.” Medscape, Medscape, 23 May 2012, www.medscape.com/viewarticle/764270.
Robey, Thomas. “The Art of Writing Patient Record Notes.” Virtual Mentor, American Medical Association, 1 July 2011, journalofethics.ama-assn.org/2011/07/cprl1-1107.html.