Writing in Medicine

- by Alon Geva '05, HMS '10

As a medical student, you are asked on a regular basis to write admission notes and discharge notes about patients. At first, you may find yourself transcribing every piece of information you learn from the patient, no matter how disjointed, along with every other bit of available data from other physicians and from laboratory results. After your first few attempts, you may be told that your notes are muddled, disjointed, and difficult to follow. When you begin to think of your task as one of analyzing available sources and distilling the most salient details from each, your notes will take shape, and you will be able to present a clear thought process to the other doctors involved in a patient's care. Your notes then become an argument for what those doctors should consider as they make a diagnosis, and you are contributing to the patient's care by ensuring that the attending physicians can readily see what evidence supports the working diagnosis, what evidence does not, and what information is still missing.