Presentations and Notes - An Introduction

Summary

In this introductory video, Dr. Eric Strong, a professor at Stanford School of Medicine, outlines a series on oral presentations and medical documentation for medical, PA, and NP students. He covers the importance of effective communication in medical history, physical exams, SOAP notes, and discharge summaries. The video discusses the evolution of medical notes, their diverse audience, and challenges such as autopopulated errors and jargon. Dr. Strong emphasizes professionalism, clarity, and the future role of AI in documentation, while highlighting the need for students to practice and receive feedback to master these essential skills.

Takeaways

• 📋 The primary purpose of medical presentations and documentation is to communicate patient information, including medical history, current condition, test results, treatments, and the clinician's thought process.
• 👩‍⚕️ Medical documentation serves a diverse audience, including physicians, advanced practice providers, patients, and the entire healthcare team.
• 📄 Medical notes are also used for insurance purposes, legal documentation, and patient access through systems like Open Notes.
• 🔍 Autopopulated data in electronic medical records (EMRs) often contains inaccuracies, and clinicians, especially students, should review and edit this information carefully.
• 🗣️ Open Notes, where patients can access their records in real-time, requires clinicians to write clear, objective, and professional notes, avoiding judgmental or stigmatizing language.
• 🔤 Avoid using obscure acronyms, paternalistic language, and terms that question a patient's credibility. Use clear and respectful language instead.
• 🤖 Artificial intelligence (AI) is expected to play a significant role in medical documentation in the future, but clinicians must still master these skills today.
• 💡 The technology for AI-assisted medical documentation is developing, but there are legal and regulatory challenges to overcome before widespread implementation.
• 📝 Mastering oral presentations and written notes is crucial for medical students, as these skills are essential for clear communication and evaluation by faculty.
• 📈 Practice and feedback are key to improving presentation and documentation skills, helping students to effectively communicate their clinical reasoning and knowledge.

Q & A

Who is the speaker in the video script and what is their profession?

The speaker is Eric Strong, who is a professor at Stanford School of Medicine.

What is the primary audience for the series on oral presentations and medical documentation discussed by Eric Strong?

The primary audience for the series is medical PA (Physician Assistant) and NP (Nurse Practitioner) students.

What does Eric Strong intend to discuss in his series on medical documentation?

Eric Strong intends to discuss the medical history and physical exam, commonly known as the H&P, SOAP presentations and notes, an alternative to SOAP, and discharge summaries.

What is the fundamental purpose of presentations and documentation in the medical field according to the script?

The fundamental purpose of presentations and documentation in the medical field is to communicate information, including patient's medical history, current condition, test results, treatments, and the clinician's thought process.

How has the intended audience for medical notes evolved over time?

Over time, the intended audience for medical notes has evolved from primarily other physicians to a more diverse group including advanced practice providers, patients, and the entire healthcare team.

What are some of the issues with the current state of medical notes as described by Eric Strong?

Some issues with current medical notes include being bloated with unhelpful autopopulated and cut-and-pasted information, lacking a coherent description of the clinician's thought process, and being full of jargon and acronyms that may not be comprehensible to patients or healthcare professionals from different specialties.

What is the 'open notes' model mentioned in the script and how does it affect medical documentation?

The 'open notes' model is a system where patients can access their own medical records in real time. It affects medical documentation by requiring clinicians to be more mindful of the language and content they use, as patients may read their notes the same day.

What are some examples of problematic language that Eric Strong advises against using in medical notes?

Examples of problematic language include language that questions the patient's credibility, is judgmental, suggests the patient is difficult, is paternalistic, easily misinterpreted by someone unfamiliar with medical terminology, inherently offensive, or highlights poor medical literacy.

How does Eric Strong envision the role of artificial intelligence in medical documentation by the early 2030s?

Eric Strong envisions that by the early 2030s, AI will play a significant role in medical documentation, potentially suggesting problem lists, composing history of present illness, and even generating entire notes based on input from clinicians.

What advice does Eric Strong give to students learning the skills of oral presentations and medical documentation?

Eric Strong advises students to practice oral presentations and writing notes, as they are not only a way of reporting and documenting information but also an opportunity to explain clinical reasoning. He also encourages students to proactively request feedback, reflect on it, and incorporate it for improvement.

How does Eric Strong describe the current limitations and future potential of AI in medical documentation?

Eric Strong describes the current limitations as the need for AI tools to be demonstrated as safe and to overcome legal and regulatory hurdles. The future potential includes AI playing a significant role in suggesting and composing medical documentation, although the exact timeline and extent of this role are not yet clear.