For better or for worse, a lot of our time in critical care in spent writing notes. in the US, these serve multiple purposes including communication, medico-legal documentation, and the basis for billing. But, I’ve found that the art of writing them is not really all that well taught. I can only speak of NP education first hand, first as a student and now as an educator, but anecdotally, I don’t think it’s much better in the MD/DO or PA worlds.
I was taught mostly by watching preceptors and reading their notes. That’s an OK strategy, except for 1) it places a lot of burden on the student to figure out why a note is good and how to adapt that to different situations, and 2) who’s to say that the preceptor is good at writing notes? I’ve had residents tell me before, “don’t worry about it. It doesn’t matter what you put in your note. No one really reads them.” But that’s wrong. On so many levels.
It does matter what your write (and how) and people do read your notes. for example, I read the notes of the people on my service who I’m following. I read the notes that consultants write, and I read the notes the primary service writes when I’m consulted on a patient. A well-written note is a great source of information and very helpful. A poorly written note can often me more of a hinderance than no note at all.
I’ve been wanting to write a Guide to Note Writing for a while, so I was really thrilled to see a great Twitter thread the other day from Robert Oubre covering this exact topic. I agree with everything he writes, so I’ll just let you read it for yourself. I will add this, your note is yours. There are right ways and wrong ways, but not one right way. The one constant I feel like I see (again, at least in NP education) is that people critiquing student notes often focus on the style points. The student doesn’t write the exact same way that they would. I’m always tempted to do this as well. I like the way I write and so I’d like if everyone else did the same. But, you’re a professional and should be able to find your own voice. But, this thread is gold.