Writing to Show Your Thought Process

Your writing is the window in to your mind. Through your writing, you can show others your carefully curated thoughts and selected experiences. Sounds fluffy and high-minded?

It’s actually straightforward to put into practice.

Let’s take these hypothetical examples of the same patient encounter:

Example 1:

A 25 year old male presents with feeling generally unwell for a few days. Says he isn’t eating well. Unsure of whether or not he had a fever. No urinary symptoms. Nausea with vomiting. Feels bloated. Complains also of abdominal pain. Feels like his abdomen is bloated. Feels worse on walking.

Example 2:

A 25 year old male presents in for diffuse abdominal pain, nausea, vomiting, and distention. 3 days of symptoms. Walking worsens symptoms. Additionally feels generally unwell, and has decreased appetite. No history of similar symptoms.

The first paragraph may very well be how the patient described his symptoms at the bedside. The second version shows that the writer has processed what the patient told them and is working their way to a working diagnosis. You probably have a working list of differential diagnoses in your head in a ranked order if you have even a couple years of clinical experience.

The first paragraph certainly demonstrates what the patient says, likely in the order that the patient says it. The second takes those same details, and curates them in a way that shows a cohesive medical story. It is the same story, but you can arrange the details to be one is more clear or less clear. As a clinician, part of your job is to make sense of what is going on with your patient and to communicate this to your fellow medical professionals. Arrange your patient’s story in a way that convinces your reader to agree with your conclusion… after all that’s the conclusion that you as a medical professional have already arrived at. So show your colleagues why you arrived at your conclusion.

The core of what makes us valuable is our knowledge and our ability to use it (my blog post on this). Our value lies in our mental processes, so let your chart reflect that.

Additionally, if you use a scribe, after each patient encounter you should briefly let the scribe know what the key points to highlight are. This way even though someone else is writing your chart, you’re still curating your thoughts carefully.

If you have more interest in medical charting or sharing a useful resource on charting with others, feel free to check out my book: The Handbook of Medical Charting