I just read an article that said, everyone on LinkedIn, claims to be a self-professed expert. Let me just say that I’m not an expert and in medicine, no one knows everything. There are days where I feel, I don;t know anything. We learn from each other in the medical community. Just like surgery residents, my mantra is “You see one, do one and teach one.”
I planned to start this blog series on LinkedIn, but was too chicken to do it. So I’m starting out here, on my website and then will hopefully share it on LinkedIn, if I ever work up the courage to do so. Plus, I get tired answering this from junior doctors and interns. I’ve been in practice for almost nine years and I know a ‘FEW’ things. 🙂
So what is this section about? It’s about the medical community and the odd queries you have, in practice or in the freelance medical writing field. You can send me your questions, I’ll post once a week with the most interesting questions. If you don’t want names, then no names will be highlighted. Sounds good so far?
Here goes.
Dr KM asked a few days ago, do you type patient notes with the patient still in the room?
This depends on who I am seeing and what I’m seeing them for.
If this is a first visit, I take my time. For the history, I take down detailed notes, and then write everything down. I have a template that I fill in. Once that is done, I do the physical and jot what’s important, numbers, vision, etc. And I don’t enter it into the EMR unless the patient’s left the room. Because a computer can break the rapport and make it very impersonal. Patients feel you’re not paying attention to them if you’re typing.
For followups, I just write the EMR straight after the patient’s gone. Either way, I do it before I see the next patient. It takes five minutes, but it’s time well spent, because then you don’t have back log at the end of the day.
Also, notes don’t have to be a chapter long. You’re not rewriting Grays anatomy! Just keep it simple. SOAP notes. Unless you’re a psychiatrist!