As a veterinary surgeon who was a meticulous over-writer, I get it. My clinical notes were often likened to War & Peace. Then I realised there was another way.
We speak to people at Vet Empowered who feel these pressures frequently too.
Common thoughts:
What if I miss writing something?
I need to articulate this properly, so I'll mention it multiple times to hammer it home.
I want to make sure the next person reading this fully understands (and if you really asked me, I want to make sure they don't judge the decision I made 👀).
The standard of detail required is quickly set in your mind, and even a routine booster rapidly becomes an epic.
The unseen side of that is how much extra time it takes; not just for you to write them, but for others to read them too.
If you too find yourself crafting over-lengthy clinical notes, I want you to know that your dedication is admirable, and there is another way.
Today, we're going to explore this challenge with kindness and curiosity, aiming to find a balance that serves both you and your patients while meeting professional standards.
Here's a nudge to be gentle with yourself, you care and that's wonderful. Growth in this area is possible though, let's imagine the difference it could make.
Efficient note taker - let's go.
Understanding our motivations to over-write
Before we dive into strategies, let's take a moment to reflect on why we might find ourselves writing extensively detailed notes. As caring professionals, our motivations often come from a place of deep commitment, care and conscientiousness. If we were to be totally honest, many times it can come from fear too. And finally, sprinkle a little 'it became a habit I never questioned' into the mix.
At Vet Empowered, we really invite you to bring curiosity and ditch the judgement here. So many of us in the profession feel the need to write very long notes, if that's you too, you're not alone.
Remember, there is support available to explore challenges more deeply, if you feel that's right for you. Not all of these will be applicable to everyone reading, and it's not an exhaustive list of motivators either.
The pressure of "PERFECT"
We say this at Vet Empowered time and time again: perfect doesn't exist. Yet, often with clinical notes we are led to believe that it does, commonly with the fallacy of more words meaning better.
Consider this:
What does the "perfect" clinical note look like to you? Would you ask this of a friend? Is this even possible? What pressures would you like to release?
Then, let's ask: "What does success mean to you in terms of clinical notes?"
(And screen it again through "would I ask this of a friend?", if it's no, go back to the question).
Is it a comprehensive novel of every observation, or a clear, concise record that effectively communicates key information?
It's worth considering whether our pursuit of perfection in note-taking truly serves our primary goal of providing excellent patient care. Could that extra time be better used elsewhere? Such as in looking after you? Sometimes, in our quest for 'flawless' write-ups, we might inadvertently divert time and mental energy from other important aspects of our practice.
The Fear of missing something crucial (FOMSC doesn't roll off the tongue like FOMO)
If we were to be truly honest - perfectionist tendencies are fears in disguise. If I make it 'perfect', then nothing will go wrong. We fear missing something out of our clinical notes that might be crucial.
Many of us have experienced the nagging worries:
"What if I forget to write down something important?"
This fear is understandable, especially given the potential consequences in our field.
However, it's crucial to notice that this fear, whilst valid, can sometimes lead us to overcompensate.
This over compensation can be to our detriment.
Let's approach this concern with curiosity:
How often have those extra details you've written actually been crucial in future treatments?
Are there patterns to the information that has proven most valuable over time?
By examining our experiences objectively, we might find that the most critical information is often captured in concise, well-structured notes. If a colleague has to skim read on a busy, we are helping them by making them to the point, rather than burying key details.
What if the next vet is judging me, or I make their life trickier?
Our worries aren't just always about what we did or didn't include, but sometimes around ensuring we are seen to be doing a good job. (Spoiler alert: you are doing a good job).
The fear about how our notes will be perceived by our colleagues is common:
"What will the next vet think of me? I really want to get across all of my rationale here"... then we write three times as much information.
This fear of professional judgment can drive us to over-explain our thought processes, leading to lengthy notes that may obscure the most critical information.
While it's important to communicate our reasoning, especially in complex cases, we need to find a balance between thorough explanation and concise documentation.
Consider:
How often have you actually judged a colleague based on the length of their notes?
When reviewing another vet's notes, what information do you find most helpful?
Is there a way to convey your rationale succinctly, focusing on key decision points?
Regulatory Scaries: Finding the balance!
The inherent worry of complaints or being 'struck off' often sparks another background-grumble-level worry that we're missing something vital. It's natural to want our notes to stand up to any potential examination, but that doesn't always mean spending fifteen extra minutes per case writing an essay. We can be accurate and concise, we promise.
Let's explore this with an open mind:
What do regulatory bodies actually require in our notes?
How can we meet these requirements efficiently?
As we'll see later, regulatory guidelines often emphasise clarity and relevance over sheer volume of information.
We've had a look for you, and this is as of September 2024, so make sure you check out the regulatory body for your country's most updated information.
Understanding Regulatory Requirements: RCVS Guidance
The Royal College of Veterinary Surgeons (RCVS) provides clear guidance on clinical and client records in Section 13 of the Code of Professional Conduct for Veterinary Surgeons. Go and read through again as a refresher.
Let's explore these requirements with a mindset of how we can meet them efficiently:
Comprehensive Yet Concise Documentation
The RCVS stipulates that clinical and client records should include:
Details of examination
Treatment administered
Procedures undertaken
Medication prescribed and/or supplied
Results of diagnostic or laboratory tests
Provisional or confirmed diagnoses
Advice given to the client (in person or over the phone)
Plans for future treatment or investigations
Proposed follow-up care or advice
Notes of telephone conversations
Fee estimates or quotations
Consents given or withheld
Contact details
Any recommendations or discussion about referral or re-direction
While this list might seem extensive, remember that efficient note-taking doesn't mean omitting important information. Instead, it's about capturing these elements clearly and concisely.
Also remember that many of these things might be attachments and part of your practice management system too, not just in the notes you write - e.g. estimates, products supplied, contact details.
Objectivity and Factuality
The RCVS also emphasises that records should be "clear, legible, accurate and appropriately detailed."
They should also be objective and factual. This aligns perfectly with our goal of efficient note-taking. Seeeee.
Reframing Our Approach: Let's dose up the compassion!
Now that we've explored our motivations and regulatory requirements, let's shift our perspective with kindness and understanding:
Efficiency is a form of care: By documenting efficiently, we're not cutting corners. Instead, we're optimising our time to provide better overall care to more patients.
Quality redefined: The quality of our notes isn't measured by their length, but by their clarity and usefulness. A concise, well-structured note can be far more valuable than a lengthy, rambling one.
Time is a precious resource: Every minute we save on documentation is a gift we can give to our patients, our colleagues, or ourselves. It's not selfish to be efficient; it's responsible.
Embracing 'good enough': Perfection is an illusion. Striving for notes that are 'good enough' – clear, accurate, and useful – can be liberating and more effective in the long run.
Strategies for Compassionate, Efficient Note-Taking
Let's explore some strategies with an open, curious mindset. These are purely suggestions and a starting point, you get to figure out what works for you.
1. Templates and Structures
Create a template that guides you through the essential elements of a clinical note - we know many of you have these already. This isn't just about restricting your writing, but about providing a supportive framework. Your template might include:
Signalment
Presenting Complaint
History
Physical Examination
Assessment
Plan
Client Communication
Many practice management systems will allow templates or shortcuts to be loaded that you can fill in.
e.g. You might have a pre-written outline for a dermatology examination, and you fill in the information (this also saves lots of typing!). You might include spaces for diet, skincare, parasite control etc.
If you can't do this on your practice management system, you could consider having a document on the desktop of your computer that you can quickly copy and paste from. (Obviously, these are templates and there are no patient details in that document).
2. Abbreviations
This won't be news to many of us, but just a reminder. Utilising commonly understood shorthand isn't about cutting corners; it's about creating a language that allows you to communicate effectively with yourself and your team. Consider:
BAR: Bright, Alert, Responsive
TPR: Temperature, Pulse, Respiration
WNL: Within Normal Limits
Remember, the goal is clarity. Ensure your team is familiar with these abbreviations, and keep a reference guide handy for less common terms. If you learn a new term that is commonly accepted, share with your team!
3. A moment for relevance
For each piece of information you're about to write, pause and ask yourself with genuine curiosity:
How does this detail contribute to understanding the case?
Will this information be helpful for future care?
Does this support my assessment or plan?
This isn't about judging the information as "good" or "bad," but about understanding its role in the patient's care journey.
4. Could tech help?
Technology can be a powerful partner in our quest for efficiency.
Explore options with an open mind:
Voice-to-text software for quick dictation (e.g. Talkatoo, Dragon Veterinary - there are lots out there)
Digital templates that guide your note-taking - as we discussed above.
Practice management systems with integrated features - make the time to chat with the company and ask what features they offer to help make note taking more efficient, many will integrate with dictation tools too.
We recently came across Scribe Note - a veterinary developed AI tool that records a conversation and creates notes from this.
Remember, the goal is to find tools that support your unique way of thinking and working.
Side note: Artificial Intelligence. A really cool exercise is to use this as your note taking tutor, and you don't even need an app. Create your own clinical note conciseness training session using a tool such as ChatGPT.
Yes but how?
Prompt ChatGPT
"My aim is to get more concise with my note taking as a veterinary professional, whilst also ensuring that I stick to RCVS Code of Conduct. The regulations are: (copy and paste RCVS Guidelines, or give the link if you ). If I give you an example of my notes (anonymised), could you give me feedback to make them as concise as possible?"
The reply from Chat GPT is usually along the lines of:
"Absolutely! Please go ahead and share your anonymised example of notes, and I'll provide feedback to help you make them more concise while ensuring you comply with the RCVS regulations."
If you input anything, ensure you have redacted any identifiers at all of this patient, do not put confidential information in. You might prefer to create notes based on a theoretical example.
Input your notes
ChatGPT will feedback based on the guidelines, give a re-done version and often will give further suggestions.
Remember, you are the professional. ChatGPT is a language model. If you think something needs to stay in, you are allowed to choose that or seek further advice.
We wouldn't suggest you do this live in practice, more as an exercise as part of training.
We also appreciate this isn't for everyone!
5. Mindful time management
Consider giving yourself a set amount of time to write your notes. Setting time limits isn't about rushing; it's about focusing. Try allocating a specific amount of time for notes after each consultation, and be aware of this whilst timing the rest of the consultation. This creates a gentle container for your thoughts, encouraging clarity and concision.
6. Flex your conciseness muscles!
Challenge yourself to summarise complex cases in a few sentences. This isn't a test, but a playful exercise to develop your summarising skills. You might be surprised at how effectively you can capture the essence of a case when you approach it as a positive challenge.
"I remember at Liverpool University, and the legend that is Derek Knottenbelt in the equine department playing a game with us as students. When we were explaining a case to him he used to say "I'm on a payphone, you have 60seconds to give me the most vital information before the time runs out", It was surprisingly effective and really made you think." - Katie, Vet Empowered Co-Founder
7. Reflect back (and learn)
Periodically reviewing your notes can be a powerful learning tool. Approach this review with curiosity rather than judgement (louder for those at the back!):
What patterns do you notice in your writing?
Which information proved most useful when revisiting cases?
Are there areas (or circumstances) where you consistently over-write?
This reflection isn't about criticism, but about understanding and growth.
Applying RCVS Guidance to Efficient Note-Taking
With the RCVS guidelines in mind, here are some outline thoughts on how we can meet regulatory requirements while maintaining efficiency:
Use templates wisely: Create templates that include all necessary RCVS-required elements. This ensures you don't miss crucial information while keeping your notes structured and efficient.
Focus on relevance: While capturing all required information, focus on what's most relevant to the case. This aligns with both RCVS guidance and efficient practice.
Separate sensitive information: By keeping financial and personal sensitive information separate, you can streamline your clinical notes to focus purely on medical information (go and read through the guidance for more info on this)
Objective language: Train yourself to use clear, objective language. This not only meets RCVS requirements but also naturally leads to more concise documentation.
Regular reviews: Periodically review your note-taking process to ensure it meets both RCVS guidelines and your efficiency goals. This reflective practice can help you continually refine your approach.
Remember, efficient note-taking and regulatory compliance are not mutually exclusive. You can write shorter, concise notes that still meet the guidance and give you time to spend with your patients (and eat lunch!).
All humans think differently!
We all process information differently, and that's a strength in our profession. Here are some ideas for different thinking styles:
Visual thinkers: Incorporate quick sketches or diagrams, for example to show locations of masses and attach to a record. A simple drawing can often convey information more efficiently than paragraphs of text. You may well have this ability integrated into your practice management systems too.
Auditory processors: Experiment with voice recording or dictation. Speaking your notes might feel more natural and efficient.
Sequential thinkers: Develop detailed checklists for common procedures. This can ensure you capture all necessary information without over-explaining.
The key is to find methods that resonate with your natural thinking style, making the note-taking process feel more intuitive and less like a chore.
Gentle steps towards change
Changing ingrained habits can be challenging, we get it. BUT approaching change with self-compassion can make a world of difference:
Start small: Begin by aiming to reduce your note length by just 5%. Celebrate this small victory and gradually increase over time.
Positive reinforcement: Notice and appreciate the benefits of more efficient note-taking. How does it feel to have extra time? How are you using it?
Community support: Share your journey with colleagues. You might find that many are facing similar challenges, and you can support each other with empathy and understanding.
Mindful practice: Bring mindfulness to your note-taking process. Notice your thoughts and feelings as you write. This awareness can naturally guide you towards more efficient practices.
Ask for feedback: If you have someone you can trust in practice, explain this is an area you are working on and would be grateful for their feedback.
A Compassionate Reflection
Take a moment to consider these questions with kindness and curiosity:
What values or concerns are driving my current note-taking habits?
How might more efficient note-taking align with my deeper goals as a veterinary professional?
What difference would being more concise make to me?
What small, kind step can I take today towards more balance in this area?
Conclusion: Embracing Efficiency with Compassion
Remember, the essence of our work as veterinary professionals is care – care for our patients, our clients, our colleagues, and ourselves. Efficient note taking is a form of care. It allows us to communicate effectively, provide continuity of treatment, and create space for the myriad other tasks that demand our attention.
As you make changes, be patient and kind to yourself.
Celebrate your progress, no matter how small.
Recognise that this shift is not about doing less, but about optimising your efforts to provide the best possible care (and including yourself in this too).
The need to write reams often comes from a place of profound commitment to your patients. By refining this process, you're not diminishing that commitment – you're channeling it more effectively.
So take a slow, deep breath, choose one small change to try, and step forward with confidence. You're not just saving time; you're enhancing your ability to care, to connect, and to thrive in your chosen profession.
You've got this, and your patients (and future self) will thank you for it!
Remember, support is always available. Be that via coaches, therapists, Vetlife, CPD programmes. Everyone is different, if you're struggling to navigate this alone, reach out.
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