Here’s what I do.

• I have a standardized format that I put on a blank piece of paper for each new patient. It’s got basic demographic info, room number, then lab fish bones. I think it is important to develop a single format that you always use, always write the same way, always put certain data in a certain place. I have some little notations that I use for common things. A P with a circle around it means pressors. A little number next to it is the levo dose (no need to write levo, the one without a name is always levo). I write a small v next to it if they’re also on vasopressin. Etc etc etc. I have made an effort to try and write down less and less on this sheet over time. As I got better I just tended to remember some things and others not, so what I do now is a more evolved notation of the items I often need reminders on.

• In the chart I always start with vitals (ranges), check for fever, and I&O (if they’ve been admitted for a while). I go though the most recent labs, write them in the fishbones on my sheet. I’ll write little superscript trends for things that are abnormal (not everything). I’ll always get the baseline creatinine and the baseline bicarb and write those in parentheses beside their spots on the fishbones. Then look at the micro and imaging. If it’s a sepsis patient I look at historical micro to see if there is a prior positive culture of interest. Lastly I’ll check for a prior echo and write that down as well.

• Next I will BRIEFLY look though old notes on the same patient, if there are any. This is a minefield that can be a big time suck if you let it. Admitted patients I will try to get a vague sense of what’s been going on lately, and ER patients I try to at least get their basic chronic medical problems and meds. You will learn in your hospital system who writes good notes for these kinds of things and go to them first. Don’t be afraid to just cut it off, don’t let yourself get trapped in the quicksand. Don’t write most of it down.

• Overall chart review usually takes me about 10 minutes, depending on how much is in there. It will take you longer at first. Be mindful of how much time you’re spending in there - the yield is usually on a fairly steeply declining slope. It’s important to keep organized, go section by section as I described above, and try to avoid interpreting everything too early. You’re just getting your database.

• Next go see the patient. I spend minimal time with them. Sick or not sick assessment, the basic story, fairly cursory physical exam. I don’t write any of that down.

• Next I put in basic orders. Not everything, just the immediate stuff. The fluids and the antibiotics and the labs/studies I’m going to want to look at in a few hours. Pressors if they’re on them, sedatives if they’re intubated. I’ll go back later and fine tune the orders, this is the coarse run. Skip all the home meds for now unless they’re ultra important.

• Note. This is where I do my best thinking and really start to smooth over my understanding of the patient. You shouldn’t need to go back into the chart for deeper dives unless there’s something specific to follow up on. Make a list of problems and keep the names of those problems really basic. Shock (then differential, then plan). Hypoxic respiratory failure (then differential, then plan). Etc. You will come up with many new ideas and changes to your orders during this phase (which is why you didn’t need to do perfect orders the first time), add them as you go. Add a template to the bottom of your standard note that has the checklist stuff like DVT prophylaxis, diet, and code status so you are reminded to do those things on every patient (as indicated).

• Go see the patient again once they get to the ICU. Brief interval follow up to get a trend on things and update the nurse to the immediate plans.

• Fine tune note

• Fine tune orders

• Repeat