Phone Note Structure
Call note structure:
Overview/Opening
Visit plan review w/ updates/status
Relevant medications
Involved results, conclusions, echo, imaging findings, etc…
Interval changes, visits, developments
Conversation notes
Recommendations/Review
SBAR format or whatever; consistency gives you a basic idea of what to expect or roughly where to look in a note for specific information.
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This sets up what's going on; a quick reference with:
the providers we're dealing with
a quick reference for when the last visit was and what it was for, but sometimes that's not entirely clear.
the patient history and background; relevant, related, or interesting items
the reason for the note; why are we here, reading this?
75(age)F(sex) patient of Dr Willson T Fid who last saw APC #3 on 5/4/24(involved providers w/ most recent visit date) for hospital f/u of NSTEMI(visit reason), Hx of CAD s/p PCI, AF on Eliquis, valve disease, HTN, HLD(medical Hx) w/ a concern about a squirrel falling off a door frame, scratches on their face w/ current OAC Tx(reason why this note is here, and yes. yes, it was.).
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Recap the last visit and everything between; this gives a chance to see what condition they were in when we last had contact, what the visit plan was, and what their projected path was to be after that.
Items that may have been lost or fallen by the wayside can be identified and resurrected from the dead hole they fell into. Overlooked medications, testing, mentions of intent to do something but no visible follow through; this may ease someone's workload in the future.
It's a bit selfish, but I hope that someone is me.
Visit plan was for:
updated echo(a test or whatever), scheduled next month(specific dates if possible)
increase lisinopril to 10 mg daily(med change plans or whatever)
monitoring lab done last week, creat up, see phone note, plan for phone check next week(whatever)
stay compliant w/ OAC, Hx extended gap off OAC, CHA2DS2 VASc of 7(more whatever)
f/u plan and when that is scheduled or recalled for, etc…(whatever else)
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I used to put 'Current Meds', but this isn't a comprehensive list of their current meds, just a list of the ones I picked out that I feel are relevant, so now I use an autocorrect or template to insert 'Current Cardiac or related meds:'
Current Cardiac or related meds:
(meds go here)
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Need to go into detail on stuff? Do it here.
1/13/24 echo(test/result) noted atrial thrombi, EF 35-40%, mild valve disease, trying to titrate GDMT. Compared to the 2/7/23 echo EF had dropped (was 60%) and the valves were unremarkable (the involved parts)
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What kind of a conversation did you stumble into?
Here's where you can share that adventure with the provider:
“Sit down good Doctor, while I regale you with the tale of your patient’s misery. We start our journey in the summer of 1968, and along the way will come to find out how she came to love her crazy cat, Mr Fluffmister, and learn about the time that crazy cat jumped up onto the Thanksgiving table…..”
Keep reading. There will be a question about her heart in there somewhere.
Patient opened her door this AM and a squirrel fell onto her head, scratching her in several areas, two of which remain oozing. She has not yet resumed her Eliquis and wonders if she should hold off for a week to allow for her scratches to heal. Also notes ongoing lightheadedness after the impact from the dislodged arboreal rodent.
She wants to know if she needs to do anything different since she is feeling lightheaded. Advised to check her BP and let us know if it is too low, since she recently had her lisinopril increased. She shares she has also held off on this increase d/t unspecified concerns. Advised to discuss this further with the provider who will be evaluating her facial wounds.
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When it comes down to it: what message were you trying to get to the patient?
Please share, so when they call back tomorrow, mis-remembering 72% of it, this part right here will be of great value.
Recommended patient continue w/ the plan as discussed at her visit, seek acute evaluation for her more recent concerns, either via PCP or walk in/ED.
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You just went through everything in painstaking detail.
Help a provider out and tell them what they're supposed to do here, and/or highlight what they need to be concerned about.
If they're reading this after a shit ass night shift, their brain is toast. Yes, they are professional, and learn, maybe, to function like this, but they are human so give them a line of help here if you can. Don't feel an obligation to just make shit up though, or push to do something just so we do something though. That's bad juju.
Please advise; would you recommend anything else for her at this point? We have a reminder in for a BP check early next week, we can see if she started anything and go from there?
This situation may not be 100% factual, but it is damn close
Consider the Next Guy philosophy with notes; this doesn’t have only mechanical or engineering applications:
This was a pain to figure out how to link. Clip everything in the original link after the ?, then replace shorts/ with watch?v=
Maybe this helps, maybe not, but mnemonics are Delicious To The Brain. That looks like it would be a mnemonic, but it’s not, I just threw a few capitol letters in there.
The below actually are mnemonics, although they are used more in acute settings (pre-hospital/EMS, ER), they can be somewhat adapted to help guide questioning and sorting out what the hell has been going on:
this is exactly what happens with mnemonics.
SAMPLE
S - Signs/Symptoms
A - Allergies
M - Medications
P - Past Pertinent medical history
L - Last oral intake (for me, this is more about recent diet changes or indiscretions like that god damn Friday night fish fry. Why are you up 5 lbs Elmer? Why? How could this possibly have happened? (to be fully transparent, this will be me, 100%, sitting right next to Elmer.)
E - Events leading up to the present illness or injury
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What the patient was doing when it started (active, inactive, stressed, etc.), whether the patient believes that activity prompted the pain,[2] and whether the onset was sudden, gradual or part of an ongoing chronic problem.
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Whether any movement, pressure (such as palpation) or other external factor makes the problem better or worse. This can also include whether the symptoms exacerbate with activity and relieve with rest.
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This is the patient's description of the pain. Questions can be open ended ("Can you describe it for me?") or leading.[9] Ideally, this will elicit descriptions of the patient's pain: whether it is sharp, dull, crushing, burning, tearing, or some other feeling, along with the pattern, such as intermittent, constant, or throbbing.
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Where the pain is on the body and whether it radiates (extends) or moves to any other area. This can give indications for conditions such as a myocardial infarction, which can radiate through the jaw and arms. Other referred pains can provide clues to underlying medical causes.
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The pain score (usually on a scale of 0 to 10). Zero is no pain and ten is the worst possible pain. This can be comparative (such as "... compared to the worst pain you have ever experienced") or imaginative ("... compared to having your arm ripped off by an alien"). If the pain is compared to a prior event, the nature of that event may be a follow-up question. The clinician must decide whether a score given is realistic within their experience – for instance, a pain score 10 for a stubbed toe is likely to be exaggerated. This may also be assessed for pain now, compared to pain at time of onset, or pain on movement. There are alternative assessment methods for pain, which can be used where a patient is unable to vocalise a score. One such method is the Wong-Baker faces pain scale.
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How long the condition has been going on and how it has changed since onset (better, worse, different symptoms), whether it has ever happened before, whether and how it may have changed since onset, and when the pain stopped if it is no longer currently being felt.[10]
OPQRST; this is right from Wikipedia. I didn’t even try:
Onset
Provocation
Quality of the pain
Region and radiation
Severity
Time (history)
