Progress Notes

September 13, 2013

I enjoy writing.  I like to put thoughts into words, and feelings onto paper.  I’ve learned it takes time, practice, and experience to do it well- to find the right words, the best sequence of sentences, and the appropriate use of punctuation.  I could spend hours on a short piece like this one, and still not get it right. 

Writing a progress note in the electronic health record is another matter.   

 My notes are full of misspelled words, run- on sentences, and poor punctuation.  I would be embarrassed for an editor to read them.  As long as the gist of the story is clear, I’m satisfied.  When I catch myself over editing, I stop.  Here’s why.     

There is always a trade-off:  if I spend more time with the note, I necessarily spend less time with the patient or my family (e.g. finishing the note after hours). 

It’s a small thing, really.  But for someone who values the written word as much as I do, it’s not easy.  I’ve resigned myself to the fact that what the patient says to me and what I say to the patient in the exam room are the most important things- no matter how it looks on paper.  

–Dean Gianakos, MD, FACP

Dean Gianakos, MD, FACP, practices and teaches general internal medicine in the Lynchburg Family Medicine Residency and Geriatrics Fellowship, Lynchburg, VA.  He frequently writes and lectures on the patient-physician relationship, end-of-life care, and the medical humanities.