The Running Note
Source transcript: The Running Note - Raw Transcript
I’ve been thinking a lot about what information is actually useful during a medical visit. The answer turns out to depend entirely on context.
There isn’t just one “clinical note.” There are several different moments in a visit, and each has different requirements.
The first is before the visit.
When I’m pre-rounding, I don’t want a complete chart. I want a synopsis. I want something I can glance at in a few seconds that reminds me who this person is, why they’re here, and what I should be thinking about before I walk into the room. The ability to drill down if I need more context is also important. What makes a good pre-visit summary is probably highly individual though. Even among internists, I’m not convinced everyone wants the same thing. There may never be one perfect tool. Instead, there may be tools that are optimized for individual clinicians.
The second context is after the visit.
This is the one medicine has spent decades refining. We write notes that become part of the medical record. For me, I still prefer the traditional HPI followed by an assessment and plan. The HPI tells the story. It explains why the assessment and plan make sense.
There has been a movement toward embedding the history for each problem directly within the assessment and plan. While that works well in some situations, I’ve never found it as satisfying. When there are many issues, repeating fragments of history over and over feels cumbersome. I still like a note that begins with a narrative, captures who the patient is and what brought them in today, and then transitions into individual problems with their corresponding plans.
But the context that interests me most is neither before nor after the visit.
It’s during the visit.
Historically, I coped by taking brief notes while the patient talked on my computer. They weren’t really sentences. They were bullet points about the story. Other physicians write on paper and dictate later. Others type directly into the chart. Everyone develops their own workflow, but we’ve never really asked what information would be most useful while the visit is actually happening.
That’s a surprisingly difficult question.
Recently, I experimented by running a few synthetic transcripts through OpenEvidence. One feature that caught my attention was its “running note.” I liked the idea immediately, but it made me wonder what a running note should actually contain.
At first, I thought it should simply summarize the facts.
The more I thought about it, the less convinced I became.
Facts are helpful, but only to a point.
What really helps me understand a visit is the story.
Every problem has a story. Symptoms begin somewhere. Decisions follow from that narrative. If the story makes sense, the assessment and plan usually make sense as well.
A running note built around the evolving story of the visit feels much more useful than one built around disconnected facts.
There’s a practical reason for this. During a visit, I don’t want to stare at the computer. I want to glance at it. A story is something I can immediately orient myself within. I’d be living it with the patient. This way one quick look can be helpful reminding the trend of the conversation and what still needs to be explored.
The only other thing I’d want is a lightweight checklist of commitments to glance at before ending the visit.
Order the lab.
Send the referral.
Adjust the medication.
Not a full assessment and plan. Just a reminder of the things I promised I would do before the patient leaves.
Interestingly, this running story may have another purpose.
By the end of the visit, we would have two different digital representations of an encounter. We would have the raw transcript, which contains everything that was said, and we have the running narrative, which would capture what the conversation meant.
Those two artifacts may actually complement one another.
The transcript provides detail. The story provides structure. Together, they may generate a better final note than either could alone.
These possibilities didn’t really exist until recently. Historically, the story lived only in the physician’s mind or in a few handwritten notes. Today, we can preserve both the conversation and the evolving narrative independently.
In the near future we’ll be discovering what this makes possible.
I suspect we’re only beginning to understand how many different contexts exist within a single clinical encounter, and how each aspect is special in its own way.