 Alright guys, what is going on? Luxury for the empty journey helping you succeed on your medical journey with less stress Now I know a lot of you guys are starting your rotations And it's probably getting to be a little overwhelming with all the stuff you have to keep up with So I'm gonna give you help today on one important thing Which is how to have a structured way on approaching every single day and how to write your notes in the morning when you do your progress No, so I'm gonna show you my step-by-step way in my computer, but let's get to the intro first All right guys, so we are in my computer and I'm going to break down kind of how I take notes Kind of when I go into the hospital for a rotation, for example, your internal medicine rotation You need to see patients you're about to pre-round on them And you want to get your notes done before like lunchtime for sure before ideally before you even Finish your rounds. So this is my structure and hopefully you guys can make some adaptations to it But I'll give you some examples and I'll break down kind of step-by-step what I do when I go into the hospital Whatever things I look for How I start to pre-write my notes and then see my patient So without like, you know talking too much to get into it So the first thing is you need to have some kind of flow on how you look at the information From the night before so the first thing I do is I always look at the overnight notes Usually the nursing notes will indicate if there's something big that happened With the patient, you know, I had a patient aware They were dizzy and they were found sitting on the floor because they couldn't make to the restroom. That's obviously important. So Read the overnight notes. You may find notes from consults. You may find it from the overnight residents figure out what happened if anything and As soon as I start reading these notes, I have my actual note I mean obviously I can't pull up the EMR, but I have the actual note that I'm about to type right next to it So mr. Johnson is the patient that I always use in my examples, right? But this first line right here is going to always be in my notes So you can just copy and forward it from your previous notes. It's just like a one-liner why they were there But then let's say our patient had some difficulty breathing and he needed some nasal cannula oxygen so if I read that in the overnight notes and I would just write that as my first sentence and Move on then my next thing is usually I would look at the vitals You know, you want to see how is their temperature? The respiration rate all that stuff You write that down on your piece of paper I'll link down below to another video that I have which breaks down how I keep all the information organized for a patient For the whole duration of their admission And I think a lot of people really enjoyed it. So I'll link it down below as well But look at their vitals look at their labs that they've came in as well as their eyes and nose But have some type of structure on what information you look at in what order that we don't ever miss anything And then I start writing My note is if I saw the patient, right? So overnight, you know, I can write this because the nurse told me on their note What happened? But in addition I'm already starting to write the note as if I saw the patient and ask them important questions, right? So if the patient was having issues shortness of breath, I'm starting to think like why would they have issues? In my examples of given this is a heart failure patient. So I'm going to say, you know whether what whether or not he had shortness of breath for specific reasons such as a pneumonia Whether he had some chest pain, you know fever things questions that I'm going to want to ask him like is this is a pneumonia Is this a PE is this just your heart failure? Are you having anxiety? Do you have any trauma? So I start writing these questions down in my note Patient says that he does or does not complain of chest pain cough fever anxiety or calf pain And I write these down in my a piece of paper that I take into the room because then all I have to do Let's say the patient says yes to chest pain and cough, but no to the final three I can just make one one sentence and then I can quickly type in patient does not complain, you know of The latter three right? This also tells you attending that you were thinking and you asked some important questions before you even went into The room your notes already starting to Get completed Here like I leave this space To obviously indicate what the patient stated happened to him So I put dot dot dot throughout my note where it reminds me like you need to make sure you ask about this And so on my sheet of paper that I take into their room I have all these things so in addition to the subjective I also do the same for the physical right so What physical exam what I do for somebody that's having shortness of breath and it's a heart failure patient So I'm going to reevaluate their JVP. I'm going to look to see what their lower extremity edema is I'm going to see what their lungs sound like I'm going to see what their oxygen saturation was are they breathing Okay, or they're you know, is their systems doing okay? And so I wrote write this in my physical section before I even see the patient Because again, it helps me remember like you need to do this on the exam And then finally I start creating a plan again before I even see the patient I'm is this going to be patient. I'm gonna start getting a chest x-ray for do I need a you know a swab Do I need to check a D dimer if I'm concerned for a PE? Do I need to check for an echo? These are all questions? I'm asking my head all before I see the patient because then After I see the patient using these pieces of information on my my thought process I can quickly take things off like I was like, okay, this guy definitely does not need a D dimer I'm not concerned for a PE right. So that's how I write my notes really quick guys. I think it takes me To do the information gathering probably five to ten minutes And then I'm doing that, you know, I'm writing the note as I'm gathering the pieces of information So it takes me maybe five to ten minutes per patient so that's anywhere from like 20 to 30 minutes to quickly scan over all your patients and have your notes like halfway done Ideally, you know, this is the patient that you've seen already. So you have some form of plan already created So this is just stuff that you're starting to plug in into addition If this is the first day you're seeing the patient obviously it's going to be longer But these are the points that I wanted to bring out Which is start writing the note before you see the patient, you know Form the questions on the you have for them write them down a piece of paper Then go examine the patient and finally fill in the details and spend a majority of your time right here Which is the you know the assessment of plan because by time your residents and your attendings want to know About the patient you spent a majority of your time On this portion. That's really where you are in your grades For honors and whatnot. So and then update come back to your note and update any piece of information You know, if you put chess x-ray and your attending decides that they don't really need one and take it out but I've always been able to more often not finish my notes before lunchtime Before often before rounds and this is the way I do it. I basically write half of it It's incomplete. Yes, but I write half of it before rounds ever started And then all I do is just fill in the information that we get From my examination and the final rounds with the team so This is just another repeat of it But hopefully this guy was helpful for you guys you guys have any other questions about writing notes and being more efficient On your rotations. Let me know But I'm gonna end the video here. So if you guys enjoyed this video, give it a like subscribe to the channel and as always Bringing more videos to you to you guys on a daily or weekly basis depending on when you guys are watching this But I will see you guys in the next video. Take care of my friends