DrVirgo
Forum Hero
Topics: 1096
Posts: 3,515
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Saving time on the patient note...
I find that I may be mentioning TOO much in my HPI and PMH so I finish my note in about 9minutes and 50 seconds... Sometimes I go a bit over 10 minutes... so I don't even get to write my DD and W/U!!! Now I'm starting to write my DD and WU FIRST, then all the relevant history, and then last the non-relevant history/physical.
Any suggestions on cutting down my time?
For example:
-For vitals, if they are not normal, can we just list the vitals as values, or do we have to say: Febrile at 101F, Tachycardic at 98/min, Hypertensive at 160/90, Tachypneic at 30/min. ???
-For FH, do we always have to mention: no DM, HTN, or Hypercholesterolemia? or can we skip it if its not relevant to the case? Or just say Parents alive and well.
-Ob/Gyn History -Is this always necessary in a woman? Or can we skip it if it's not relevant to the case?
-Enough to say for normal CV exam: Normal S1/S2, RRR, no M/R/G, no JVD, PMI non-displaced. ???
-Enough to say for normal Chest exam: CTA and percussion B/L, Tactile Fremitus WNL.
-Enough to say for normal Abdom exam: Soft, NT, ND, + bowel sounds, Tympanic to percussion in all 4 quadrants, no masses or HSM. ???
-Extremities: No edema/cyanosis/clubbing?
-Where do we mention peripheral pulses?? In extremities or in CV???
Any other ideas on how to save time during the Patient Note???
Thanks. 
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Our greatest glory is not in never falling, but in rising every time we fall.
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| sprint123
Forum Guru
Topics: 129
Posts: 870
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Hi virgo!I think OBGYN is a must for a female in every case -But not in detail regarding to the case. We can ask how many kids do you have?when was you LMP? Is the cycles regular? and I think we don't have to mention that in our PN if not significant.
Also, I am not sure whether we could use RRR and CTA in our abbreviation as this is not given in the usmle CD!
It is enough to list the vital values!!
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| DrVirgo
Forum Hero
Topics: 1096
Posts: 3,515
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For Ob/Gyn I usually ask G/P/A and the LMP date?, regular cycles?, any spotting?
But even that seems to be too much as it sets me back on time if its not relevant to the case.
___________________
Our greatest glory is not in never falling, but in rising every time we fall.
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| faraym
Forum Addict
Topics: 23
Posts: 795
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Make some photocopies of the PN and practice writing on them only Try this and you'll finish faster . Because there isnt much space to write the whole story. Better to practice and prioritize.
Unless its a pain abd.Ask only LMP and how many kids and any problems with periods.
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"Bindu ki maa, Jab Jab jo jo hona hai ,tab tab so so hota hai." from Padosan.90/85/pass
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