r/Residency • u/rash_decisions_ PGY2 • 1d ago

SERIOUS How to be more thorough?

I’ve gotten the feedback a few times about being more thorough with my patients in terms of both asking them HPI questions and their chart.

Sometimes I feel weird asking them questions I should know (it’s already in their chart somewhere) and sometimes I just don’t know what to ask because I don’t know what’s relevant.

I also have a hard time digging through their charts. It’s often times overwhelming and too much information, so I don’t bother.

Any ideas on how to slow down?

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u/CriticalCaptcha 1d ago

With meeting patients, use the phrase “I looked through your chart” - many don’t know until you tell them. “Hi, I read about your history of *** in your chart, but I wanted to make sure nothing got lost in translation, can you tell me more about (whatever you need to find out).”

If you get overwhelmed in a chart, one tip is to look for pathology records, op notes, procedure notes - if it’s important enough to do something invasive or get tissue, you should know about it. Or, hope they’ve had an ID consult recently /s …but not really.