Table 3.

Selected examples of least effective and most effective practices across all levels of performance

Situation	Least effective practices	Most effective practices
Reading practices	Selective reading practices including: 1 ∘ The most recent progress note and laboratory values 2 ∘ Neglects notes written by nursing and other allied health providers Depends on other team members to advise on active issues to follow up on Searches for specific information requested by the team	Comprehensive reading practices including: 1 ∘ Admission documents 2 ∘ Notes from nursing and allied health professionals 3 ∘ Previous team progress notes 4 ∘ Overnight orders 5 ∘ Clinical documentation from previous encounters Seeks out individuals to verbally discuss the patient and receive updates (nurses, allied health, senior medical resident) Looks for progression, patterns and trends of issues over time Screens for and anticipates potential complications and side‐effects of current and proposed treatment Reviews active issues and medications when trying to determine the causes of abnormal investigations or physical findings
Patient encounter	Does not utilise chart review prior to seeing the patient to guide the clinical encounter Conducts generic history and physical examination regardless of active issues or patient familiarity	Pre‐reads patient chart and reviews new laboratory results to identify active issues to address at the bedside Conducts a focused history and physical examination pertaining to active issues and patient complaints
Composing practices	Responds to abnormal laboratory values without necessarily understanding/identifying a cause Documents physical examination findings that were not personally observed, but were previously noted When covering a peer's patient, defers responsibility of advancing patient care until team member returns Does not investigate or follow up on unclear information	Reviews and refines active issue list Seeks out missing or unclear information to clarify Double‐checks the accuracy of previously documented information Independently studies the literature and reviews patient cases to address knowledge gaps before seeking assistance Consolidates information from various sources into a comprehensive problem‐based note that reflects refinement of active issues in the context of the patient's chronic problems
Textual features	Includes all issues into a single SOAP note Uses the same format for all patients regardless of clinical complexity	Problem‐based documentation with a separate SOAP or equivalent headings for each active issue Documentation reflects progressive collaborative refinement of active issue
Informal notes	Inconsistent approach for keeping track day to day Takes notes on his or her patients only Uses notes to record information in case trainee is ‘pimped’ by the team	Writes key information from morning review for his or her own patients, as well as for those being cared for by other members of the team Uses personal notes with checkboxes on patient list to keep track of completed tasks and reminders for the day Keeps an additional set of notes on each patient being followed, listing chronic and active problems, medications, results of key investigations and other pertinent information to track progress over time