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I sometimes struggle to decide what I truly need to include and what is plain to see from the chart (ie. vitals, meds, procedures, even medical history). All of this shit is documented already and it’s a major drain to do repeat work for no reason. I’ve shifted to writing template MDMs that cover my ass and just adding to them as needed. Most patients fit into an easy category. It doesn’t help the next doc, but it keeps me sane.
It’s a discharge summary, not a daily journal of events. If my intern wrote more than a paragraph on that patient, I would be disappointed. They would get a lecture about concise documentation that focuses on pertinent events from me. No one wants to read a novel, including us attendings :)
We have this hematologist in our university who is known to be brilliant. He's good with patients one-on-one but All of his notes look like that. Then he orders a bunch of labs and he doesn't send any sort of explanation to the patient or to me and straight up ignores direct messages to him to clarify