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.

Outlines

00:00

👨‍🏫 Introduction to Oral Presentations and Medical Documentation

Eric Strong introduces a series on oral presentations and medical documentation aimed at medical, PA, and NP students. He will cover the medical history and physical exam (H&P), SOAP notes, alternative formats, and discharge summaries. The primary purpose of these documents is to communicate patient data, clinician thought processes, and care plans. Originally intended for physicians, the audience has expanded to include the entire healthcare team, insurance companies, and even patients.

05:01

🗂️ The Evolution and Challenges of Medical Notes

The purpose of medical notes has expanded beyond physician communication to include advanced practice providers, the entire healthcare team, insurance companies, legal documentation, and patients. This has led to notes being bloated with unnecessary information and jargon. The series aims to teach principles for creating valuable medical notes despite these challenges, emphasizing clarity and accuracy, especially in electronic medical records (EMRs).

10:02

📝 Effective and Respectful Documentation in the Age of Open Notes

With patients now able to access their medical records in real-time (Open Notes), clinicians must ensure their documentation is professional, objective, and free from jargon and stigmatizing language. Examples of problematic language are given, along with suggestions for more respectful and precise alternatives. This transparency is important for building trust and ensuring clear communication with patients.

🤖 The Future of Medical Documentation with AI

Artificial intelligence (AI) is expected to play a significant role in medical documentation within the next decade. While AI can assist with generating notes, it will never completely replace the need for human oversight and clinical reasoning. Students must still master traditional documentation skills to ensure safe and effective implementation of AI in the future. AI's role will evolve, but experienced clinicians will remain essential for complex cases and oversight.

📚 Practice and Mastery of Oral Presentations

Eric Strong emphasizes the importance of practicing oral presentations, which are crucial for student evaluation but rare in independent clinical practice. Presentations and notes showcase a clinician's reasoning and understanding of medical knowledge. He advises students to seek feedback, reflect on it, and continuously improve their skills, as these presentations are key in assessing practical medical knowledge and reasoning.

Keywords

💡Medical Presentations

Medical presentations refer to the process of conveying information about a patient's medical history, current condition, and treatment plans. In the video, Eric Strong emphasizes the importance of clear communication in medical presentations, which is crucial for effective patient care and collaboration among healthcare professionals. The script discusses the evolution of presentations from being solely for physicians to a more diverse audience including advanced practice providers and patients themselves.

💡SOAP Notes

SOAP is an acronym for Subjective, Objective, Assessment, and Plan, which is a method of medical documentation. The script introduces SOAP notes as a traditional format for organizing patient information, but also suggests that there may be alternative formats that could be more effective. SOAP notes are part of the broader discussion on how to improve medical documentation for various stakeholders.

💡H&P

H&P stands for History and Physical examination, which is a comprehensive record of a patient's medical history and the results of a physical examination. In the script, the H&P is mentioned alongside SOAP notes as a component of medical documentation that is essential for understanding a patient's condition and formulating a treatment plan.

💡EMR

EMR stands for Electronic Medical Record, which is a digital version of a paper chart that contains all of a patient's medical history from one practice. The script discusses the use of EMRs in creating medical notes, highlighting the convenience of auto-population features but also the need for clinicians to verify and edit the information for accuracy and clarity.

💡Open Notes

Open Notes is a movement where patients are given access to their own medical records in real-time. The script mentions this as a new context for medical documentation, requiring clinicians to be mindful that patients may read their notes, thus advocating for clear, objective, and professional language that respects patient privacy and dignity.

💡Healthcare Team

The healthcare team refers to the group of professionals involved in patient care, including physicians, nurses, therapists, and other specialists. The script highlights the importance of medical documentation as a means of communication among this diverse team, ensuring that all members are informed and can collaborate effectively.

💡Medical Jargon

Medical jargon refers to the specialized terminology used in the medical field. The script advises against overusing jargon in medical notes, especially in the context of Open Notes, to ensure that patients can understand their medical records without confusion. It suggests balancing the use of medical terms with clear, accessible language.

💡Clinical Reasoning

Clinical reasoning is the process by which healthcare providers analyze patient information to arrive at a diagnosis and treatment plan. The script underscores the importance of conveying clinical reasoning in presentations and notes, as it demonstrates a clinician's thought process and helps others understand the rationale behind their decisions.

💡AI in Medical Documentation

The script discusses the potential future role of artificial intelligence in medical documentation, suggesting that AI could assist in generating problem lists, diagnostic data, and even entire notes based on patient interviews and medical records. It also raises considerations about the safety, legal, and regulatory challenges that need to be addressed before widespread adoption.

💡Medical Terminology

Medical terminology refers to the specific language used by healthcare professionals to communicate about medical conditions and treatments. The script provides examples of problematic language use, such as stigmatizing acronyms or judgmental terms, and encourages the use of clear, objective, and non-discriminatory language in medical notes.

💡Practice and Feedback

The script concludes with advice for students to practice oral presentations and seek feedback, emphasizing the importance of these skills in medical education. It highlights that presentations and notes are opportunities to demonstrate clinical reasoning and understanding of medical knowledge in real-life situations, and that practice and feedback are key to improving these skills.

Highlights

Introduction to a brief series on oral presentations and medical documentation intended for medical, PA, and NP students.

Discussion of the medical history and physical exam, SOAP presentations and notes, an alternative to SOAP, and discharge summaries.

Purpose of presentations and documentation: Communicating patient medical history, current condition, test results, treatments, thought processes, diagnoses, and plans of care.

Historical context: Originally, notes were for communication between physicians, but now they serve a diverse audience including various healthcare professionals and insurance companies.

Challenges with modern notes: Notes often fall short in addressing specific purposes, can be bloated with unhelpful information, and may lack a coherent description of the clinician's thought process.

Importance of adhering to fundamental principles and a consistent format in medical documentation.

Tips for electronic medical records (EMR): Ensure accuracy by editing autopopulated information, updating past medical history, and confirming medication lists with patients.

Documenting in the era of Open Notes: Be aware that patients may read their notes in real time, so documentation should be objective, professional, and free from stigmatizing language.

Examples of problematic language in medical notes and how to improve them.

Future role of AI in medical documentation: AI may suggest problem lists and compose notes, but clinicians must still ensure safety and accuracy.

Current importance of mastering medical documentation and oral presentations, despite future AI advancements.

Oral presentations and written notes as opportunities to explain clinical reasoning and demonstrate practical medical knowledge.

Oral presentations and notes as tools for faculty to assess student understanding and reasoning skills.

Advice for students: Practice oral presentations, seek feedback, and incorporate it to improve skills.

Conclusion emphasizing the ongoing relevance of mastering medical documentation and oral presentations in student education.

Transcripts

hello my name is Eric strong and I'm a

professor at Stanford school of medicine

this is an introduction to a brief

series on oral presentations and medical

documentation intended primarily for

medical PA and NP students in this

series I'll be discussing the medical

history and physical exam commonly known

as the hmp so-called soap presentations

and notes an alternative to soap which I

think is actually better and discharge

summaries

I'll also be incorporating some examples

of

presentations in this introduction I'll

be discussing a few things that apply to

all forms of presentations and medical

documentation in

general to start what is the purpose of

presentations and documentation whether

you're considering an hmp soap note or

discharge summary or are considering

oral versus written forms the primary

purpose of all of them is communicating

the information that's communicated

includes most obviously data about a

patient's medical history their current

condition test results and treatments

provided but it's more than that it also

includes information about your own

thought process what it is that you

think is going on with a patient what

diagnoses do you think are most likely

to explain their condition and why do

you think that how does the data support

your conclusions and last how did you

decide on the plan of care originally

presentations and notes were composed by

physicians with a primary intended

audience of only other Physicians

however over time their purpose has

grown in scope and with the increasingly

complex delivery of care the audience

has become much more diverse so today

it's not just about communication

between Physicians it's also about

communication between Physicians and AD

advaned practice providers such as

physician assistants and nurse

practitioners communication also extends

to the patients in entire Healthcare

team including but not limited to nurses

respiratory therapists physical and

occupational therapists case managers

dietitians and

pharmacists For Better or Worse in some

countries including here in the US

written notes are also a way to

communicate to insurance companies in

order to justify medical billing and to

compare patient outcomes between

institutions notes in the medical chart

are legal documents that can be examined

and used as evidence in court in the

event of an adverse patient outcome and

more recently with the ability of many

patients to access the medical chart

electronically in real time a model

known as open Notes the notes can

communicate information directly to

patients

themselves specifically regarding the

written notes of today with such a

diversity of purposes and audiences they

often fall short of perfectly addressing

any one specific purpose each individual

reader might find only a small portion

of the content to be relevant to their

needs the notes can be bloated with

unhelpful autopop populated and cut and

pasted nonsense that is not even

accurate they can lack a coherent

description of the clinician's thought

process they can be full of jargon and

acronyms that are not only

incomprehensive to patients but also to

any Healthcare professional from a

different specialty than the writer my

intention with this series is to teach

you and to show you how medical notes

and or presentations can still be

valuable tools in the delivery of modern

Healthcare if we adhere to some

fundamental principles and a consistent

format and

organization there are some specific

tips related to the electronic medical

record or EMR in most places in the

world world including every hospital in

the United States notes such as hmpps

and soap notes are composed directly in

the EMR using templates which autop

populate a large variety of data this

can include past medical history

medication lists smoking and alcohol

history vital science and lab results

it's very common for busy multitasking

clinicians to just run with this autop

populated information without even

checking it let alone editing it for

clarity but particularly for students I

strongly encourage you to do so as just

implied the autopop populated

information is wrong with surprising

frequency at the absolute minimum you

should ensure that the past medical

history is updated and completely

resolved issues have been removed and

that the outpatient medication lists

have been confirmed with the patient in

many cases the process of autopop

populating templates can place equal

emphasis on data of vastly different

importance so a patient's autopop

populated problem list might have 30

items in which their heart transplant is

sandwiched between hosis and

heartburn there are also tips for

documenting in the era of open Notes

which as I mentioned is when patients

can access their own medical records in

real time in short keep in mind that

anything you write in the chart could

potentially be read by the patient the

same day not that it was ever okay to be

judgmental or rude in the chart

beforehand but this is even more

motivation to keep everything you

document as justifiable supported

objective and professional as

possible I personally don't think that

open Notes means that we should discard

virtually all medical terminology to

make the notes maximally readable by

patients now a vocal minority of

clinicians do advocate for that but I

think doing so leads to ambiguity and

less Precision in communication and in

my experience most patients don't want

that they want access to the information

but they don't want the information

watered down however I do think you

should air on the side of avoiding

unnecessary obscure acronyms you should

be extra cautious with documentation

around mental health substance use and

sexual history and you should abolish

the use of stigmatizing and more subtly

coded language and charts which you

might think is providing helpful

information to other clinicians but

which often perpetuates bias and is

infuriating to patients when they pick

up on

it let's see some examples of language

that's

problematic there is language which

questions the patient's

credibility the patient claims that

Ibuprofen is ineffective or the patient

denies recent alcohol use instead of

claiming or denying the patient reports

something did or did not help or did or

did not

happen language which is judgmental the

patient refuses vaccination due to

conspiracy theories her cousin shared on

social

media Instead try the patient is

declining vaccination due to concerns

regarding toxicity and side

effects language which suggests the

patient is difficult the patient is well

known to me from countless visits to our

ER related to his ongoing drug abuse we

can change that to I am familiar with

this patient from a prior ER

visit language which is inherently

paternalistic the patient refused her

morning Labs although there are extreme

circumstances in which the word refused

is appropriate for example the patient

refused emergent surgery for their type

A aortic dissection but in most cases

the word declined is

preferable language easily

misinterpreted by someone unfamiliar

with medical terminology

the patient's so returned yesterday s so

is an outdated acronym for shortness of

breath but in American English it is

also a semi-of slang

term language which is inherently

offensive the child is an LK which flk

is an acronym for funnyl looking kid

meaning someone appearing syndromic and

as awful as that sounds it was a very

common term thrown around when I was in

medical

school and last the use of quotes to

highlight poor medical literacy the

patient reported she ran out of her

quote sugar pill weeks

ago I want to be transparent with

medical notes and artificial

intelligence we aren't there yet in 2024

but for any firste student by the time

you are finished training and are

practicing independently so by the early

2030s I expect that AI will be playing a

significant role in medical

documentation

precisely what that role will look like

is not yet clear and will certainly

evolve over time it may start with AI

suggesting a problem list from the

preceding note and diagnostic data

chatbots based on large language models

including chat GPT can already do this

as well if not better than first and

seconde medical students how soon will

it be until a computer listens in on our

patient interview and combined with

mining the medical chart for additional

data autoc composes the history of

present illness in an

hmp and how long will it be after that

until we provide the computer just our

physical exam and the AI composes the

entire note including the assessment and

plan needing us to just edit a few

things here and

there no one can offer specific time

frames for when these changes will

happen but it's not just a matter of the

technology because the technology is

more or less already there these AI

tools also must be demonstrated to be

safe and there will be non-trivial legal

and Regulatory hurdles to overcome for

example who would be responsible for

harm caused by an error in an AI

composed medical note however these

changes they are coming at some point

within our

lifetimes with that in mind I appreciate

that it might seem unnecessary to master

a task that eventually will be

predominantly Outsource to

technology yet these are still important

skills for clinicians in training to

learn today

because the technology hasn't been

implemented yet and we can't predict

when that will happen we will need

clinicians familiar with how to

optimally communicate information in

order to implement these changes in a

way that is safe and improves patient

care and it's never going to be perfect

as an analogy think of ECG machines and

their ability to diagnose arhythmia on

their own are ECGs frequently correct

yes a timesaver for overworked ER Docs

yes a useful support tool for staff not

well trained in ECG interpretation also

yes always correct definitely no an

experienced clinician comfortable with

ECGs can still outperform the machine

algorithms on complex arthas it will be

a long time before there is no role at

all for human intervention in medical

documentation now perhaps in 25 years

this video series and this entire skill

set will be obsolete but for now writing

medical notes remains a core skill in

medical practice and delivering oral

presentations remains a core part of

student

education I'll end this introduction

with a final word of advice for students

who are learning these skills for the

first time practice practice oral

presentations and to a lesser extent

practice writing notes the ability to

give a clear and organized oral

presentation which includes a level of

detail appropriate to the patient and

situation will play a disproportionately

large role in your evaluation by faculty

this is a little ironic since fully

licensed and independent clinicians

rarely if ever need to give an oral

presentation but remember that oral

presentations and written notes are not

just a way of you reporting and

documenting objective information they

are also your opportunity to explain

your clinical reasoning that is why you

think one diagnosis is more likely than

another and why you think certain

treatments are more appropriate than

others in a particular patient

presentations and notes are an excellent

way for faculty to assess whether a

student or intern is able to understand

and apply very practical medical

knowledge in real life

situations personally I learn more about

a student's knowledge and reasoning

skills from a single oral presentation

on a new complex patient than I ever

could from traditional written exam so

practice proactively request feedback

reflect on it and incorporate it for

next

time