Issues and Impressions

I often find myself frustrated with notes from teams on the wards.

Many excellent notes will start with an impression and a background medical history of the patient. Over a long hospital admission, the patient will often accumulate many issues set out in a clear list. This format sets the context for the patient. It illustrates a story and helps all caregivers understand who this person is and why they’re here. Sometimes though, the team’s note is extremely detailed and gives absolutely no inkling of what they think is actually going on. If another doctor is called to see them after hours, how do they best help the patient?

In ED, as I think in all parts of the hospital, it’s crucial that you communicate your intention in your notes. When we don’t do this, miscommunications happen and patients are harmed.

Why it Matters

Clinical uncertainty is a big part of the job in ED. We usually start treating patients far before a diagnosis is obvious. We often don’t have the time to exclude all clinical uncertainty in a few short hours. Writing a differential, the dangerous diagnoses we have excluded, and ongoing clinical uncertainties help guide the next clinician if a patient gets worse. It also makes it more obvious which parts of their investigation need rethinking.

The impression is the most important part of your note. None of the detail you write matters if you cannot put it together into what you think is happening.

An Example

You have a young man in his early 20s who has had some abdominal pain and nausea. He has some features on history and examination that could be caused by appendicitis but others that don’t really fit. He now feels well, his blood tests are normal and you’re wondering what to do next.

If it’s in-hours you could get an ultrasound, but this is not always available. Sometimes an ultrasound doesn’t see the appendix at all. You don’t want to do a CT on every young person with abdominal pain if you can help it. You also don’t want to miss an appendicitis.

There are many approaches. Talking it through with the patient is a great start and you can share the decision. Let’s say the patient is now comfortable and you can’t justify a CT scan. It’s also 10pm on a Saturday evening. He goes home for expectant management (watch and wait). Two days later he represents with worsening pain and now has obvious appendicitis. What did you write in your note?

In the former note it looks like you could have made a mistake or oversight. In the latter, your thinking is clear and your patient did what you asked them to. This becomes crucial when patients prefer to do something you don’t recommend like discharge home when you asked them to stay in Short Stay overnight.

Some Structure

So, you’ve done a thorough history and examination. You’ve collected all their medications and past medical history. You’ve gathered collateral from family and the paramedic notes. What do you put in the bit before the plan?

On the ward many teams will write an issues list, but I only use this if a patient has several things going on. The way I tend to structure impressions is by writing down what I think it is, what it could be, what it’s not and what is still uncertain. In med speak this is your working diagnosis, a differential diagnosis, excluded dangerous diagnoses and unanswered questions.

You are bringing together all of the disparate bits of data gathered in your assessment and distilling them into a sentence or two. This takes a lot of practice. 

Write your impression and your plan before talking to your boss about your patient. They can then critique you and show you what you could improve.

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