One day while working in the Accident and Emergency department I had a very complicated patient, and by that I mean there were several problems happening at once. These were all internal medicine issues. Between the history, examination, the consultation and the problems presented I felt overwhelmed and out of my scope. Defeated, I went to my Consultant to discuss the patient next steps.
What happened next was a moment of clarity for me, and my frustration brought forward a valuable lesson in medicine that I think was missing my entire career.
Assessments have always been an issue for me, constantly I’ve been told that I write my assessments oddly or don’t utilise the jargon appropriately. Medicine, as much as it is a science, is also an art. We could be saying the same thing…. But there is usually a “proper” way to say it- or rather write it. Until this moment, no one had ever taught me how to come to my assessment and write it out. You really just learn in, like a lot of other things, by doing, following others and “figuring it out”.
I felt like a medical student, as I sat in my consultant’s office, docket in hand, they pulled out a piece of paper and a pencil “okay. Tell me the history”. And I did just that, going through the story, I had to start over and write over twice, trying my best to remember all the key points, sometimes jumping all over the place when something came to mind. It was hard to follow- even if you drew it out. This is exactly what my notes looked like. Basically like word vomit.
They jotted each point down and when I was finished started to categorise the points. Suddenly, patterns and differentials started to emerge… and within 20 minutes, my hour plus long consultation with the patient had been sorted, an assessment made and a plan made and executed. I was so impressed that I actually took the paper with the notes to keep as a reminder!
Recently, I had the opportunity to try this out. I was faced yet again with another multi complaint and complex patient. However, I was confident in my ability, not only to gather information for my history, but present a compelling case and find assessments that made sense, followed the jargon and guided my plan. I would be lying if I said I didn’t feel super proud of myself and honestly- empowered as a knowledgeable and capable physician. Let’s get into the method… to the madness!
Why Is A Clear Assessment Important?
To me, your assessment is a quick glance of the history and examination, it is your list of differentials, their current state or status or what you think is happening with the patient. Anyone should be able to look at your assessment and understand immediately your train of thought. Not only does it give clarity but it guides your plan. Sometimes I found I would forget things in my plan because my assessment was inadequate, but you can almost go point by point and see how each plan corresponds to each assessment.
How Do I Make An Appropriate Assessment?
Everything starts with your story, the history. My cheat sheet for this is either my review of systems, or ruling in and ruling out differentials… often times I use a mixture of both.
Say a patient comes in with shortness of breath, this could be caused by a myriad of things, it could be cardiac, respiratory or otherwise. You can choose to ask questions going by systems or you could ask questions to rule in or rule out diagnoses such as asthma, heart failure or even a foreign body.
Categorising everything makes it clearer in your mind what it could or couldn’t be. This is very simple to do when its only one complaint- but what happens when its multiple? The best way I have found this is to tackle each complaint one by one- almost as if I’m doing separate mini histories for each. And then taking a step back and seeing what is connected and what isn’t. Is the patient who comes in with shortness of breath, abdominal pain and headache having one pathology occurring or multiple? The more and more complex and/or numerous patient presentations and complaints get, the more and more you have to get back to basics.
Here’s my favourite part, grouping the signs and symptoms. You can do this automatically in your mind or write it down- up to you. This I have found also guides my examination, because by this point I’m simply trying to rule in and rule out differentials versus doing a general examination and hoping I find something ‘sus’…. Option one is the better one!
How To Tie It All Together
I’m still working on this one, I’ve never been great with medical jargon but I am making an effort to try. Since being taught I have approached all my patients in the same way and have seen the changes in how my consultations go. My notes are clearer, easier to follow, my assessments are succinct but informative and my plan is way more comprehensive. That one small change has improved my entire ability to practice medicine.
This is going to be different based on the case, rule of thumb is to group assessments and make necessary commentary. If someone comes in with decreased responsiveness and you found that they had a stroke you could simply write “CVA” short for cerebral vascular accident or you could write Decreased responsiveness secondary to stroke with left hemiparesis…. Now tell me- which one gives you more information?
Also, prioritise your assessments. Let’s say this same patient has hypertension with high pressures and dyslipidemia and benign prostatic hyperplasia (BPH). How do you prioritise that? Go from most urgent to least urgent.
Decreased responsiveness secondary to stroke with left hemiparesis then Uncontrolled Hypertension (you may comment here if its Urgent or Emergent or anything of the sort depending on the numbers and patient infront of you) then Dyslipidemia and BPH.
How Does This Help My Plan?
Sure, writing CVA, Uncontrolled BP, Dyslipidemia and BPH might be enough… technically but you may actually find that your plan may suffer. I’ve realised that looking point by point at my assessments reminds me of my plan. A lacking assessment may make you forget to take off certain labs, or simply write an incomplete plan because you don’t have a reminder or a snapshot of the patient that you’ve seen.
At the end of the day, your notes are more than just a record, it’s a story, when you or anyone else is reading them you should be able to have an accurate and appropriate picture of the patient in front of you. Persons should be able to follow your train of thought, and not feel confused as to why you chose to do one thing over another. Not only that, when you go to discuss your case with your seniors it looks very well put together and a little impressive!
So learn from me, even after three years of practicing, I’m learning something new. It seems almost obvious but I wish someone had kind of spelt it out and frankly- dumbed it down that much for me. It has literally been a small change that made a huge impact in my confidence, my ability to assess and treat patients and keep myself accountable and remind myself of the next steps all in the attempt to ensure I have provided comprehensive and appropriate care.
I aim to stay teachable, and even when it sucks, chin up and learn so I can be a little better everyday.
I want to hear your thoughts! What are your best tips for writing assessments?
Dr. Samantha Johnson