SOAP notes have been a real source of pain for me here lately. Each professor expects something different yet they all say the examples in our book (Koda-Kimball) would be great. They then say they want extra stuff in them..

My question is this what do you put in your Assessment and Plan?

We are having to do Pub-med searches and find new articles to support our claims. Do you assess these articles or just site them as your reasons in your plan?

You'll never be able to please an instructor with a SOAP note. I never was, anyway. I found that each instructor had THEIR way of writing them.

Which means, you'll have your own way, too. Doesn't do you a whole lot of good now, since you're being graded... :)

I don't cite in my patient notes. I have the references available to me if I am called on it. The trick is to be as short as possible, while conveying your thoughts. Long SOAP notes=skipped SOAP notes.

What do I put in my A/P? Anything I think of. The S/O will be dictated by any lab values or any info you got from the patient. The A/P will state what you think of the data, what you want to recommend to do about it, and how you want to make sure it is being done. If it would help, and if I get a chance, would you like me to paste in a SOAP I did yesterday? LMK.

Most of the time, your institution will dictate how the notes are going to be entered.

I work with an EPIC system that autokeys the labs in, so I don't have to do the O part. Also the P part is automatically linked to the CPT/ICD-9 billing system (which is cool!), so I am constrained on my language.