Why Do Patients Even Need to Take Notes?
- We are managing more complex health situations than ever before and that requires patients and care partners to carry out more complex treatment plans – often from multiple physicians and specialists. We can’t remember everything all the time and we may encounter conflicting instructions. It’s helpful to have notes.
- Our records ‘live’ in many different databases and they don’t all communicate. Patients and care partners are often the only ones to navigate among disconnected offices and their databases. You may be asked about previous tests and results because a physician just doesn’t have access to records. Being able to answer questions can be a patient-safety issue.
- Appointment times are short. A big part of taking good notes is in the preparation. It’s helpful to have a place to write down questions and symptoms before having your appointment. A lot of ground can be covered in 10-15 minutes when you’re prepared and focussed.
What Do ‘Good Notes’ Look Like?
There are 3 criteria for taking good notes:
- You have a designated place for taking/keeping notes. You need to be able to find them when you need them. And since you’ve already created your patient binder you can check this off the list.
- Your notes include the date. It’s helpful for finding information and keeping things in order, especially when plans and instructions change.
- You have a process for writing down answers and action items so you can be confident that you’re doing what you need to be doing.
Pro Tip: You can also ask for a copy of the electronic notes a physician has made during your visit. Many will print them off for you before you leave the office. These are helpful and you can check that you and the physician are on the same page.
There’s a Downloadable Sheet!
We developed this clinic notes sheet and print out a few blank ones for each section of our binder. We add new sheets to the front of each section so the notes have the most recent sheet first.
You’ll see that there are some questions at the bottom of the sheet. These come from a book called, ‘How Doctors Think’ (Dr. Jerome Groopman). He explains how sometimes the way doctors are taught to think can trip them up when they’re making a diagnosis or recommendations – because all systems have cases that don’t seem to fit in. Asking these questions can be helpful in your discussions. Find more information at this blog post: How Doctors Think: A Book for Patients & Families.
Download a template for your medication list here: Clinic Notes
If the template doesn’t work for you, you can create your own system using the criteria above.
The basics of your patient binder are in place! It’s time to develop the habit of taking it with you for every appointment so you can take notes and share information if/when needed.
Do you have questions about taking notes? Did you make some adaptations for your own situation?
