Any resources for writing SOAP notes??

[Cups123]

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Any good online resources designed to teach beginners who have never written one before? Esp for simple problems such as cold, flu, etc...I am not in rounds yet but we have to write them and I am really confused, especially since I don't have most of the medical lingo down to begin with...

 

[Blade28]

Lots of good helpful links below.

 

[Toohotinvegas33]

Your school doesnt provide info on how to write soap notes? do you have a texted?

http://www.elsevier.com/wps/find/bookdescription.cws_home/707210/description#description

 

[gschl1234]

Any good online resources designed to teach beginners who have never written one before? Esp for simple problems such as cold, flu, etc...I am not in rounds yet but we have to write them and I am really confused, especially since I don't have most of the medical lingo down to begin with...

Therre's the "SOAP for..." series:

http://www.amazon.com/SOAP-Internal-Medicine-Angelina-Badillo/dp/1405104368/ref=pd_sim_b_title_2

Also "First Aid for...whatever rotation" always has a list of abbreviations.

 

[smq123]

Any good online resources designed to teach beginners who have never written one before? Esp for simple problems such as cold, flu, etc...I am not in rounds yet but we have to write them and I am really confused, especially since I don't have most of the medical lingo down to begin with...

I think that writing SOAP notes for simple problems (cold, flu) is actually harder than writing SOAP notes for more difficult problems (pneumonia, people who just had surgery). There's almost nothing to write in SOAP notes for people who have a cold.

What kind of medical lingo are you having trouble with? The abbreviations, or the actual words?

 

[Cups123]

The actual words - like cough, is there a fancy word for this? how about red, runny eyes - its conjunctivitis but when you are describing it in the appearance section i'm assuming you don't write conjunctivitis but rather a fancy way of describing red, runny eyes??

 

[smq123]

The actual words - like cough, is there a fancy word for this? how about red, runny eyes - its conjunctivitis but when you are describing it in the appearance section i'm assuming you don't write conjunctivitis but rather a fancy way of describing red, runny eyes??

Oh, I see.

No, you can just call it a "cough."

If you wanted to be really fancy-schmancy, you could say that the "conjunctiva are injected and eyes appear irritated," but I would probably just say "pt's eyes are red and watery."

When it comes to physical exam, you really don't have to rely on fancy language to be a good student on the floors - just describe what you hear and what you see. You can use plain language if you have to - it's much better to use regular language than to use the wrong word for something!!

 

[gschl1234]

The actual words - like cough, is there a fancy word for this? how about red, runny eyes - its conjunctivitis but when you are describing it in the appearance section i'm assuming you don't write conjunctivitis but rather a fancy way of describing red, runny eyes??

Before you get to A/P, you should keep to good descriptions rather than an assessment such as "conjunctivitis." There's nothing wrong w/ a good descriptive S/O that everyone can understand. Sometimes we make things too hard for ourselves by using words that nobody understands. Our dean was just saying the other day that when we see a pink rash, people will use the word "erythematous" (which means "reddish") rather than the more specific term "pink."

 

[PeepshowJohnny]

Don't go overboard on learning to write the "perfect" SOAP note. Your attendings and residents are all going to have different ways they want you do write yours so the best thing is to be flexible.

You're going to have some flipping out that you didn't document the presence or absence of tactile fremitus in your O section (on a patient in for cellulitis) and then some wanting a note and report that's basically states "Patient alive, here's what we're doing"

 

[TrustDrDice]

Your school doesnt provide info on how to write soap notes? do you have a texted?

http://www.elsevier.com/wps/find/bookdescription.cws_home/707210/description#description

that's a good book actually - read it

 

[Blade28]

Don't go overboard on learning to write the "perfect" SOAP note. Your attendings and residents are all going to have different ways they want you do write yours so the best thing is to be flexible.

Agreed.

 

[doctorFred]

Don't go overboard on learning to write the "perfect" SOAP note. Your attendings and residents are all going to have different ways they want you do write yours so the best thing is to be flexible.

i was once corrected for saying "a 37 year old female..", since female is "primarily an adjective." i was supposed to say, "a 37 year old woman." it still doesn't sound right, since everyone else (in both real life and tv) says female.

 

[MedGoatTX]

some wanting a note and report that's basically states "Patient alive, here's what we're doing"

i.e. surgery

Best notes you'll write all year.