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Sample progress notes + presenting patients

Discussion in 'Clinical Rotations' started by beastmaster, 06.17.07.

  1. beastmaster

    beastmaster Senior Member

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    Not sure if this exists anywhere online, but does anyone know where I can find like a database of sample SOAP notes, and also a guide on how to present patients to the attending.
  2. predodoc

    predodoc Junior Member

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    Im looking for the same info. Im about to start my 2nd week of IM and I know Im going to do a crap load of them this week.
  3. raidermedic

    raidermedic MS IV

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    Don't know about online but you can find a sample SOAP note in First Aid for the Wards.

    For presentation it depends on the service

    My basic presentation went like this

    Pt name
    CC or status post what procedure
    Overall how the pt is doing today
    Vitals (would point out values not WNL. Otherwise would just state WNL)
    PE: Focused at this point. ie for pt with pneumonia how are there lung sounds
    Lab Values/Radiology studies
    Plan for the day

    A good method to use is to photocopy your soap note and use that on presentations. At first you will be reading directly from it but as you go through the rotation you will learn what is important and what is not in presentations. By the end you become so used to it that you can ramble off your pts from memory only looking at your little cheat sheet for specific lab values.
  4. retroviridae

    retroviridae Senior Member

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    So the medicine approach ....

    For old patients:

    This is Mr. Jones, our 55 y/o male (+/- the diagnosis, depends how well the team knows him). He had an uneventful night and is without complaint this morning. His vital signs are afebrile, pulse 92, RR 18, BP 126/72, POx 98% on RA. His Is/Os were xxx. He had XX BMs yesterday (for narcs or possible c diff). His weight is xxx (for heart failure, volume issue patients, etc). His exam findings are [some attendings want a full exam, most just want you to focus on the pertinent system(s)]. His labs from yesterday (or any back in the am) are. Yesterday's diagnostics tests/consult recs were .... In summary, he has xxx and my plan today is: [some attendings will accept a one/two liner here, others will want a complete systems based approach].

    You have to taylor this to your patient and your attending. There is a fine line between so much info the team's eyes glaze over (but be warned, some attendings want that and you are rarely faulted for saying too much).

    Admission notes, you all know the pattern. In terms of what questions to ask for each patient, that will come with time. You kind of have to listen to enough history to get at a reasonable differential and then go from there. As a med student, I recommend just taking the system he is complaining about and exhausting the history for that. Actually, I pretty much do that now anyways.

    PLEASE practice before you present. I always make my med students present to me or the intern prior to rounds with the attending. We should be able to guide you if your organization is going astray etc.

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