My site evaluator for my first rotation was Professor Sadat. During my site evaluations, I presented several SOAP notes that I had written on patients from my time in Emergency Medicine at NYPQ. I was offered constructive criticism on writing and presenting my SOAP notes. The first SOAP note I presented was a case about a 45-year-old female experiencing “stomach pain.” From my presentation, it was clear to Professor Sadat that I was thinking like an emergency medicine clinician when considering my differential diagnoses like ectopic pregnancy and myocardial infarction. My presentation of a 29-year-old female complaining of palpitations and “intense heart beat” included pertinent negatives like “denies family history of sudden cardiac death, personal or family history of anxiety disorders,” etc. Some advice I received was a recommendation to, under the Assessment/Plan portion of my notes, make clear which medications were being given “one time” or just for the duration of the hospital course, rather than them appearing as though they would be continued after discharge. Furthermore, Professor Sadat mentioned that my assessment and plan can be more detailed regarding the diagnosis related to the patient’s chief complaint. Another recommendation that was made, that I will keep in mind for future rotations, is noting the patient’s MRN number. If the site evaluator has privileges at the hospital, we can learn about the remainder of the patient’s hospital course. Another case I presented on, in addition to a journal article related to the diagnosis, was a 77-year-old female with a left hip fracture after falling. I ordered the proper labs and imaging for the patient that would be required prior to her orthopedic consult and subsequent surgery. My article presentation was succinct, but thorough enough to explain the major points from the review on treatment modalities for a variety of hip fracture types.

One of my classmates, Lilly, was also rotating through the NYPQ Emergency Department and was part of my Site Evaluation group. It was great getting to listen to the cases she saw in the Emergency Department and to what drugs she found were commonly prescribed. Not surprisingly, there was some overlap in our choices. My other classmates, Loretta and Katrina, also presented on cases from their rotations in Family Medicine and Ambulatory Medicine respectively. It was great experience getting to listen to their case presentations and being able to reflect on some history taking skills, such as certain pertinent positives and negatives that they chose to include, that I can, in the future, adapt in my practice.

Going forward, my action plan to improve at future site evaluations includes being more thorough when writing up the “Assessment/Plan” portions of my notes. I will accomplish this by asking for constructive criticism from my preceptor and colleagues regarding my notes overall, but with a focus on the Assessment/Plan portion. Additionally, I can review notes that my preceptor writes up to get an idea of what they include under these sections.