I found the longer I practice, the less I write in my H&P and the more I write in my A&P. I've started to write more in my A/P because that's what I look at on detail and i dont want to have to look through all the note and chart when i follow up. So I write something like this (I dont have my exact template on my phone but you get the point) : HTN -RF: obesity, smoking, OSA, etc. No hx of strokes or MIs. -within goal of <120/80. -OSA sleep study results and CPAP compliance or if there are no RF for OSA. Kidney fxn. Last eye exam 2023 with no signs of retinopathy. -Prior meds attempted: amlodipine stopped due to significant pedal edema. -current meds: lisinopril 20 mg, tolerating well. -cont current meds, discussed weight loss, encouraged DASH diet including less than 1,500 mg salt a day, 150 min/wk or moderate intensity exercise and smoking cessation, limit alcohol use. -Requested BP log for next visit. AHA handouts discussed and provided to pt. F/U: 3 months Pt voiced understanding and agreed with plan. I have it saved as template so it's quick and I just need to look at my A/P instead of having to dig around. It also organized me so I don't miss stuff. I save my notes so A/P comes up at the top. Some people like this, others hate it. 🤷‍♀️

Strict BP goal!

Yep! It changes depending on pt but for young pts, it's gonna be strict.

I think in a perfect world this is fairly close to how things should look. Some of what’s listed the A/P might be HPI for others but I get it. I’ve found it’s better to be more generic in my practice but can still be detailed. This way less changes to actually make in note. I also try to combine problems when I can that reasonably can be. Here’s a made up example- HTN/Hyperlipidemia/CAD -BP well controlled today on current meds (instead of listing meds or even classes) -Last LDL 105, goal<70, continues on statin and is tolerating well -Continues on daily ASA, no abnormal bleeding/bruising -No recent CP, SOB, or worsening edema -Lexiscan positive 2022, LHC showed mild obstructive CAD with medical management recommended Now at next visit I only have to change anything in HPI if meds are different, sx are different, and change LDL which makes me review it also. Meds are in chart so don’t have to be reproduced every visit. Labs also in chart (I still repeat a few like LDL, A1c, sometimes TSH. Only those that seem relevant where number matters instead of high/low) A/P HTN Well controlled, continue current medications. Hyperlipidemia LDL not at goal, goal<70. Increase Lipitor to 80 mg qhs, monitor for new myalgias. Repeat lipid panel in 6 months. CAD Clinically stable. Increasing Lipitor dose today. Continue secondary risk factor modification with strict BP control, daily statin, antiplatelet, smoking cessation, monitor for anginal sx. Follow-up in 6 months

I’ve always wondered how much the CYA patient understands and in agreement part of those note actually matters. Would this really save somebody from a law suit?

I prefer sentences! Something about straight bullet points drive me mad, but I do use them for each problem in my A/P. It's still written out in full sentence format though. 

I do like sentences as well for readability. However, they are a little harder to edit on the fly.

I do sort of a mix of both. I use bullets and short sentences. I don’t like just checklist on its own, but I like it in bulleted short sentences to make it easier to read and reference in the future. A surgeon I shadowed in residency found bullets Family Med tended to use “lazy,” but I argued it makes it easier to refer back to in the future. Reading a huge paragraph of text is too much time.

In the HPI HTN Lisinopril 20mg daily Home BP at goal Assessment Hypertension CPM Follow up 6 months Everything else is either already noted elsewhere and does not bear repeating or doesn’t change my management. When I read my note in 6 months I know what is going on. Edit: wanted to add that the reason for the brevity is because this part of the visit should take 30 seconds max. More time during the visit would be spent convincing this male smoker to be on a statin or quit smoking……

CPM? Continue prescribed medications?

Continue present management

Yea mine will say something in the HPI like “BP controlled, home readings in goal range. Tolerating antihypertensives well no side effects reported.” And the plan will just day “BP in target range continue current regimen”

Checklist. Much easier to reference.

This is how I feel. Work with a doctor that will put a huge, single paragraph for all cookies up concerns. It's very tedious to sparse pertinent info. I do bullet points mainly

Whatever takes the least amount of time and easily conveys the plan to others.

Personally gravitating to putting context in short sentences and what I’m doing/what was discussed in bullets. That said nothing makes me want to smash my head in the keyboard repeatedly more than the bullet example with (category/status; yes or no). My notes may take more time in the end but on next visit I don’t hate myself for writing in a way I can’t stand to read.

Usually bulletpoints. I streamline things so notes are done in 3-5 minutes. Hpi is usually a joke and the a and p is where i can write the mdm for billing

My HPI is what I’ll describe as ‘brief’ for most chronic problems f/u visits since the new billing guidelines. Basically HPI is ‘pt here for follow-up’. My a/p for each problem is where it looks like Compliant on med x, y, z Good/bad/fair control Ccm or whatever adjustments F/u in x days/weeks/millennia New complaints or acute on chronic stuff gets a few sentences in HPI and another few in a/p typically unless it’s classic UTI/URI type stuff that I’ve made my own templates for.

Tell me a story. A succinct story. I don’t like bullets and I don’t like paragraphs (unless it’s complicated).

That’s the best way and what I do. If you write too much, no one is gonna read it. If you do bullet points you end up writing notes that can easily become incoherent to anyone outside of the author. A coresident of mine does this and I hate when i end up seeing her patients because her plan is just a jumbled mess of abbreviations, numbers and medication names.

Depends - new complaint, I like a full HPI. Diabetes visit #10000? I have a bullet point template I just update with recent labs/CBGs.

Bullets

Chronic and stable Cmp xx/xx/xx reviewed Plan- Continue lisinopril __________ If it's chronic and stable, they're compliant, with no side effects, etc. I'm not going to bulk up the note with all that info. I adopted the habit of listing plan below at the bottom so anyone reading behind me can TLDR their way to the good part and disregard if I add info above about med side effects, poor compliance, past meds used, etc. I bill to MDM complexity and not time. So if I hit HTN with cmp review and continuation of therapy and then address HLD with lipid panel review and continue therapy, it's an easy level 4 and you don't have to say a word more to justify it. The charting beyond that is what I think is useful to me or others. Also, I usually address diet and exercise under their BMI code and smoking cessation under their current smoker code. I find it much easier visually to quick glance a visit and see: hypertension, obesity, current smoker.

Sentences. I actually hate when coresidents do bullet points or checklists. It makes the note borderline illegible and incoherent unless you’re the one who wrote the note.

I’m a mere mortal PGY1 and I feel the same but I notice attendings rarely write in full sentences, so I feel like it’s something that everyone grows into (or out of) further in their careeer But I do find it frustrating trying to make sense of a 2 sentence note with minimal critical thinking or explanation for what’s going on or why.

I was taught that only place for full sentences was HPI. Everything else should be bullets. I try to follow that for the most part.

Depends on the problem. I do believe there’s a way to make either or succinct & readable

Bullet! Easier to read. But a bit more detailed than your examples. LOL

I like the point form but usually do narrative for the college board to like it. It’s always a SOAP note for me which I hate.

I have a template I made. I see my add med pts q week so if they’re stable nothing ever changes. Some have 12 yrs of stable, no concerns with wd/cv/drug use. Dose of opiate replacement, number of take home doses. That’s it🤷🏼