Presentations and Notes - An Introduction
Summary
TLDRIn 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
👨🏫 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.
🗂️ 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).
📝 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.
Mindmap
Keywords
💡Medical Presentations
💡SOAP Notes
💡H&P
💡EMR
💡Open Notes
💡Healthcare Team
💡Medical Jargon
💡Clinical Reasoning
💡AI in Medical Documentation
💡Medical Terminology
💡Practice and Feedback
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
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