Confused about SOAP note etiquette

[sprinkibrio]

I'm a little confused about SOAP notes (I'm on medicine)...

I get in at 5 am to see my patients, look up their labs, and write my SOAP note before the intern and resident get in at 7 am. Then we all meet at 8 am for work rounds. 10 am is attending rounds.

My question is should I be updating my SOAP note with addendums that include pertinent labs that come up later in the day and changes in assessment and plan if I was totally off with my first assessment and plan? If so when should I do this? If I do it after work rounds it's more timely, but if I do it after attending rounds it will be the 100% sure plan.

I always thought SOAP notes were for overnight events, not to list every patient lab in the past 24 hrs. I also thought SOAP notes were supposed to show what WE know and think the plan should be, not the actual plan (although if I got it right, that would be nice.)

I ask this because my third year partner in crime doesn't show up until the intern and resident do and writes his notes after work rounds. I'm sure the resident gets mad at him for it, but the attending is probably looking at it saying "wow that's a great discussion and plan" without looking at the time it was done. I'm afraid it's making me look bad. Then he updates his note with like 2 or 3 addendums for small changes in plan and what I think to be inconsequential lab results. The attending has to sign off on addendums each time, possibly 15 times a day when he has five patients.

Am I the one that looks bad and is doing it wrong or is he? We fight about this a lot, but none of our uppers will give us a straight answer.

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[rock_climber]

I'd ask your intern/resident what they want. I'm not 100% on this, but I think I would add an addendum if it was important but I wouldn't be listing every lab value. I def. would not make the attending sign off on every addendum, I'd be pissed if that were me!

 

[Droopy Snoopy]

Keep in mind that probably your partner is new at this just like you and simply has a different thinking on the way things are supposed to be. True gunning exists and really sucks, but for the most part try not to let little things like this get at you unless you know s/he's deliberately trying to make you look bad. Medstud notes aren't given much notice by anyone. In general attendings evaluate based on actual face time during rounds. While a small percentage of attendings may look favorably on being meticulous by keeping up with changes in the plan, I think the vast majority view it as making extra work if they have to take the time to sign off on every brainwave that runs across your partner's mind.

It sounds like you've already talked to your interns/resident about this and they blew you off? That stinks. What also stinks is assigning 5 Medicine patients to an M3 in July. You can't possibly be learning anything.

 

[Twitch]

Just use your best judgment. If new labs come in that weren't there @ 5am or whenever you wrote them down and are of particular interest - cx comes in saying what grew, one the chem values is out of whack, H/H tanks, read comes in from rads that the team was waiting on to make clinical decision - stuff like that is important. Unless you absolutely need to have your notes in the computer before rounding (which sounds odd), just jot down a brief soap on paper - present on rounds - then write out a flushed soap on the computer in the afternoon but don't sign the note - just save it. Gather any additional info as needed, update note if needed -> save -> sign.

 

[sprinkibrio]

Thanks for the advice everyone. I've come to the conclusion that I'm doing it the right way, although I might benefit from occasionally adding addendums that include morning labs that didn't come in before I finished my note or especially pertinent afternoon findings + my interpretation of them and how this changes the plan. I guess that's the best I can do.

I don't think my partner is gunning... he's definitely just lost like me... but a little too confidently lost.

The only thing my resident did say is that we need to get notes in before resident rounds because it helps him and the intern and that we need to keep track of patient's new info in the afternoon. I got a bit insecure about this whole thing since my partner was SO adament his way was the one correct way. I keep trying to get him to come in earlier so he stops typing away all afternoon with his attending approved A&Ps while I look like a lazy bum reading after I've finished patient stuff... sigh.

I've also come to the conclusion that hospitals are very, very different! I didn't think 5 patients was *too* many, although luckily I don't pay a lot of attention to the 2 or so "back pain" or "headache" patients I get after ruling out everything but drug-seeking. And unfortunately, our attending sees everything we write and must sign off. He gets a love note through the computer when I'm done with a note. Thanks again... being critiqued and reassured is important... gotta learn how to ask residents and attendings for that...

 

[OncoCaP]

I'm a little confused about SOAP notes (I'm on medicine)...

I get in at 5 am to see my patients, look up their labs, and write my SOAP note before the intern and resident get in at 7 am. Then we all meet at 8 am for work rounds. 10 am is attending rounds.

My question is should I be updating my SOAP note with addendums that include pertinent labs that come up later in the day and changes in assessment and plan if I was totally off with my first assessment and plan? If so when should I do this? If I do it after work rounds it's more timely, but if I do it after attending rounds it will be the 100% sure plan.

I always thought SOAP notes were for overnight events, not to list every patient lab in the past 24 hrs. I also thought SOAP notes were supposed to show what WE know and think the plan should be, not the actual plan (although if I got it right, that would be nice.)

I ask this because my third year partner in crime doesn't show up until the intern and resident do and writes his notes after work rounds. I'm sure the resident gets mad at him for it, but the attending is probably looking at it saying "wow that's a great discussion and plan" without looking at the time it was done. I'm afraid it's making me look bad. Then he updates his note with like 2 or 3 addendums for small changes in plan and what I think to be inconsequential lab results. The attending has to sign off on addendums each time, possibly 15 times a day when he has five patients.

Am I the one that looks bad and is doing it wrong or is he? We fight about this a lot, but none of our uppers will give us a straight answer.

If your partner in crime is making the resident mad, that could be trouble for him when it comes to evaluation time because the attendings tend to poll the residents about students. My SOAP notes are for the past 24 hrs at the hospitals where I have written SOAP notes (not just for overnight). As a general guide that I use, to maximize your grade, the notes need to be in the chart before the resident rounds your patients (or your service). You should make the assement and plan as "real," concise, and complete as possible. If there is a key lab value or procedure pending, you may wish to write an addendum once it comes it and indicate the implication. When I'm doing well with these, my resident or intern may write something to the effect of "agree with the above" put a few comments about what s/he found and sign it. If your training is similar to ours, you will want to get to the point where you are writing a SOAP note that is something your resident or intern will feel comfortable signing off on with fairly minor additions / revisions. There are also differences on the consult SOAP vs inpatient SOAP in terms of content and focus.

That said, there are seemingly countless ways to do these notes (including a few lines of virtually unintelligible scribble that I don't recommend) and countless different expectations. The main thing is to find out diplomatically what your attendings and/or residents want and give them that. You should ask the students a year ahead of you as to what certain attendings look for (because what they say they want and what they grade highly are, at times, different). If I was totally off on my assessment / plan, it usually means that I did not consider a sufficiently extensive differential. It's my impression that you want to avoid saying more than you have to but never less. You should use your resident's notes as a guide about what should be in your note. You don't want to jump to conclusions that you cannot support, and thus you should always have a logical note that isn't really subject to being completely off. Your clinical info, labs, and imaging should support whatever you determine in your assessment and drive your plan. In key places I usually put something in there like "will monitor for clinical SSx of X, Y, Z" to show that I'm thinking of other possible issues that are not high on my list for now but I can only write about the top 2-3 differentials. I'm not sure why you would need to put in a significant number addendums unless you were following pts in the ICU perhaps.

 

[45408]

man, I'd be pissed if I had to show up at 5am on my medicine rotation. There was ONE time I got there before 7am, and that was at 6am. And no, I don't write addendums. I just put that info in the next day's chart. Besides, it's not like labs will be forever lost if you don't write them in the progress note.

 

[BigRedBeta]

Don't update with labs. If something comes back as critical, that's a little different, particularly if it's time sensitive (ie a patient has a potassium of 8.3), but a note shouldn't delay you calling your team. Once you've done an intervention, obviously that needs to be documented, but simply updating labs is not worth your time.

Third year is your chance to "play doctor", especially early on. Come up with a treatment plan, but expect it to be ignored, so don't be offended, and it's rare to get "graded" on your plan. If you dont' get to present your plan to the attending, make sure to go over it with your intern or upper level resident for feedback. Unless you're completely offbase, doing things that are dangerous, or otherwise inept, your plans are unlikely to affect your evals. The main thing is, everyone knows you don't have a good grasp on clinical medicine yet and therefore are going to have gaps in your approach.

And unless it's taking you 2 hours to see all your patients and get everything written, don't come in at 5. I think it's good to get your notes in before the resident, but it's not worth losing sleep over. If they're getting check out at 7am, you may be missing information anyways about what happened over night. If it is taking you 2 hours, you need to work on becoming more efficient.

 

[ucsfstudents]

Everyone does SOAP notes differently, so your best bet is to get early and timely feedback from your resident and attending, check their notes against yours, ask how you could be doing things better and differently. Ultimately, it's the facetime with the attending and your presentations that count the most when it comes to evaluations from your attending. Of course you never want a resident mad at you.. hence the periodic feedback sessions you should ask for. Oftentimes, if you don't ask for feedback, they won't give it to you until the end of the rotation. Good luck!

 

[sprinkibrio]

And unless it's taking you 2 hours to see all your patients and get everything written, don't come in at 5. I think it's good to get your notes in before the resident, but it's not worth losing sleep over. If they're getting check out at 7am, you may be missing information anyways about what happened over night. If it is taking you 2 hours, you need to work on becoming more efficient.

It does take me that long and I'm definitely working on being more efficient... especially since I want to try and read before my note to have a solid plan. I don't know if this is common for medicine or my hospital or what but the problem list averages 5 problems and on post-call days where we've just got a consult, three images done, and added a bunch of fluids or meds it can be hard to record all the new data, do a physical exam reflecting new findings, and write everything up in the computer. I've heard 45 min per patient is good at the beginning... on a post call day it takes me about that time. The further we are from call the quicker I am since new information is limited... we're normally just waiting on studies or improving function.

I know I could ignore certain info, but as a med student I feel like I need to record everything new about my patient just in case... 🙁

 

[igottaquestion]

man, I'd be pissed if I had to show up at 5am on my medicine rotation. There was ONE time I got there before 7am, and that was at 6am. And no, I don't write addendums. I just put that info in the next day's chart. Besides, it's not like labs will be forever lost if you don't write them in the progress note.

Yeah, why the heck are you getting there at 5, if you resident-round at 8? I do my pre-rounding in about an hour.

 

[igottaquestion]

I know I could ignore certain info, but as a med student I feel like I need to record everything new about my patient just in case... 🙁

Just pls tell me you're not doing full H+Ps on your pts each morning . . . Otherwise just don't take this approach with rounding. As someone with little experience myself in clinical medicine, I would still think that the ability to determine which lab/PE info is relevant is a skill that can be looked upon favorably. Sure, you might miss something, but the intern and resident will be there to fill in the gaps. I'm wary of boring my attending/resident/intern with laundry lists of findings during rounds, and instead try to point out abnormal or pertinent normal findings, and offer some interpretation of what I think is going on and what should be done. If you screw up, you'll be corrected and you'll learn. It's still better to try to be an intern, imo.

 

[sprinkibrio]

Just pls tell me you're not doing full H+Ps on your pts each morning . . . Otherwise just don't take this approach with rounding. As someone with little experience myself in clinical medicine, I would still think that the ability to determine which lab/PE info is relevant is a skill that can be looked upon favorably. Sure, you might miss something, but the intern and resident will be there to fill in the gaps. I'm wary of boring my attending/resident/intern with laundry lists of findings during rounds, and instead try to point out abnormal or pertinent normal findings, and offer some interpretation of what I think is going on and what should be done. If you screw up, you'll be corrected and you'll learn. It's still better to try to be an intern, imo.

Full H&Ps? Do you realize you're being insulting? If you really don't understand the time it can take on medicine, I'm wondering if you're on surgery or something else this month or just don't remember what it's like starting out.

It takes me 30-45 min/patient and I have 5. Although I know what is the *most* relevant and only present this information in 2-5 min, I write down everything I think I might possibly be asked about. I was asked the other day about a diet-controlled diabetic's HbA1c was... not a diabetic on meds or a diabetic with end-organ disease... a weight & diet controlled, completely asymptomatic former diabetic. The value was from a year ago. I don't mind being diligent, more diligent than you would have to be on surgery for example. Sometimes lots of things change overnight based on new labs/imaging and I have to figure out the next step in the plan... I try to incorporate reading into that. I also have a patient who currently transfered from the ICU with a lovely number of labs coming in everyday. I do have room to speed things up, this I know. I think some may come from speeding up the data gathering process but most will come from a larger knowledge base... aka no more advice needed. I'll just go read.

I think it's a poor showing to have the intern or resident fill in on patient info. We're supposed to know more about the patient than anyone.

 

[Gute]

Full H&Ps? Do you realize you're being insulting? If you really don't understand the time it can take on medicine, I'm wondering if you're on surgery or something else this month or just don't remember what it's like starting out.

It takes me 30-45 min/patient and I have 5. Although I know what is the *most* relevant and only present this information in 2-5 min, I write down everything I think I might possibly be asked about. I was asked the other day about a diet-controlled diabetic's HbA1c was... not a diabetic on meds or a diabetic with end-organ disease... a weight & diet controlled, completely asymptomatic former diabetic. The value was from a year ago. I don't mind being diligent, more diligent than you would have to be on surgery for example. Sometimes lots of things change overnight based on new labs/imaging and I have to figure out the next step in the plan... I try to incorporate reading into that. I also have a patient who currently transfered from the ICU with a lovely number of labs coming in everyday. I do have room to speed things up, this I know. I think some may come from speeding up the data gathering process but most will come from a larger knowledge base... aka no more advice needed. I'll just go read.

I think it's a poor showing to have the intern or resident fill in on patient info. We're supposed to know more about the patient than anyone.

I agree with you. It takes a long time to preround on medicine if theres alot of new info, especially if you want to go over everything. Its embarrassing sometimes because I don't know as much about my patients as I should, despite the amount of time I spend on them.

 

[igottaquestion]

I think it's a poor showing to have the intern or resident fill in on patient info. We're supposed to know more about the patient than anyone.

I was referring to intern/resident input on the A/P. If you think the world's going to end because you didn't get to the hospital at 5AM to look up a former diabetic's year-old HbA1C "just in case" the attending would ask about it and the intern would show you up by giving the answer, then by all means go save the world super stud. 😉

 

[smq123]

My question is should I be updating my SOAP note with addendums that include pertinent labs that come up later in the day and changes in assessment and plan if I was totally off with my first assessment and plan? If so when should I do this? If I do it after work rounds it's more timely, but if I do it after attending rounds it will be the 100% sure plan.

Why even bother updating your A/P? 😕 If you were wrong, you were wrong. No big deal.

I think you're taking the assessment/plan portion of the SOAP note wayyyy too seriously.

The MS3 SOAP note is, fundamentally, to be used for YOUR learning. Can you synthesize labs? Can you present a clinical picture of any events that happened overnight? Can you recognize clinical emergencies when they occur? Can you decide what the next step should be.

No one else really cares about the MS3's A/P. No one reads it that closely (except for teaching purposes), the nurses don't follow it, and the lawyers can't use it in court. (Med student notes are not even considered part of the patient's medical chart, legally speaking.)

[The only other people who "care" about your note are the JCAHO people - because JCAHO can ding anyone, even the chaplain, for not dating and signing the note. But they don't really care about the actual content of your note.]

So definitely no reason to update it. If you were wrong, you were wrong. Learn from it, and try to do a better A/P next time.

It takes me 30-45 min/patient and I have 5. Although I know what is the *most* relevant and only present this information in 2-5 min, I write down everything I think I might possibly be asked about.

For starters, 45 minutes per patient is a LOT - I would say too much, for a regular floor patient.

Secondly, are you writing down "everything you think you might possibly be asked about" on the SOAP note? There's definitely no reason for that. A HgbA1C value doesn't belong on a daily progress note. While I would say that it's important in the admitting H&P, there is absolutely no reason to note that down on a daily SOAP note. A SOAP note should ONLY note events that occurred within the past 24 hours - and space should not be spent documenting something that is a year old.

(Yeah, it's great that you knew the patient's A1C value. However that info should be on your team's patient census, again - not on the SOAP note.)

I also have a patient who currently transfered from the ICU with a lovely number of labs coming in everyday. I do have room to speed things up, this I know. I think some may come from speeding up the data gathering process but most will come from a larger knowledge base... aka no more advice needed. I'll just go read.

The speed doesn't come in the data gathering process; it comes in learning what's not that crucial.

If a patient is coming out of the ICU, do you need to note all their labs? Probably not. ABGs, CBC, LFTs, BMP/CMP, and TSH are important. But, for instance, one of my fellow students not only wrote down the CBC on his SOAP notes, he wrote down the ENTIRE WBC differential...and trended them. That's overkill. It doesn't add anything to your clinical decision making, generally, so why waste time?

I think it's a poor showing to have the intern or resident fill in on patient info. We're supposed to know more about the patient than anyone.

It's technically the intern's job to know more about the patient than anyone. While I applaud your attitude, and think it'll take you far in med school, you're not the only one responsible for the patient. 😉

 

[sprinkibrio]

I never really thought that the SOAP note was for my learning only... I can see that. I do know my attending sometimes (usually?) reads them... and critiques them. I guess that's why I was so concerned.

 

[smq123]

I never really thought that the SOAP note was for my learning only... I can see that. I do know my attending sometimes (usually?) reads them... and critiques them. I guess that's why I was so concerned.

I honestly didn't think that the SOAP note was mainly for the student's learning, until I was told that, at some schools, students aren't even allowed to put their SOAP notes in the chart! They have to carry them around until the intern has a chance to review them and offer feedback, and then they are discarded. Sucks, and a bad policy (in my opinion).

Sure, of course you're concerned with what your attending has to say when he reads your SOAP notes. That's normal, and that's one of the reasons why, as a med student, you SHOULD work hard on your SOAP note. (The other being that it's good practice for residency.)

But you don't have to fix the assessment and plan AFTER your attending has critiqued them. It's not that big of a deal.

 

[sprinkibrio]

But you don't have to fix the assessment and plan AFTER your attending has critiqued them. It's not that big of a deal.

Nice 👍

 

[plainolerichie]

You could try to write out the SO part, write out the problems part of the assessment, but then wait for the plan and some not-100%-sure-assessments when presenting to the residents. Then, verbally discuss the assessment and plan during work rounds with the residents, but just write it down after work rounds. Then write it out and maybe make minor changes after rounding with the attending. That'll save time and that's how I would do it on surgery.

But just ask what the residents want you to do. In medicine, we did not have to have any notes written before rounding and would work on them during the day AFTER work rounds and/or rounding with the attending. We were expected to preround for ON events, possible new pertinent labs, any new major complaints/PE findings. It's not lazy or gunnerish, it's just the way it works for everyone at my institution. Our notes and A/P's were co-signed and placed in the chart with no other notes from our team for that day, so they were edited to be more accurate. Actually, that's how every rotation worked except for surgery and what the other med student on your team is doing sounds basically how it usually works. Never had to show up at 5 AM for medicine, only at most 20-30 minutes early for pre-rounding.

 

[BigRedBeta]

Agree with the concerns over putting ALL the lab data into a SOAP note, that's unnecessary (if that's what you're in fact doing). I remember the feeling thinking I should have all the little minutia on my patients, but you need to carry that information elsewhere - notecards, forms from medfools.com, a PDA, whatever works for you.

It's not poor form if you don't know the answers. It's really okay. And you have to remember, the interns have a little bit more insight into what's important and relevant. If you're simply mining the history in case you get pimped about previous labs or a prior admission, your yield on how useful that information will be becomes significantly lower. Then your just wasting time. If you do desire to make sure you know the details, do your hunting during the downtime. In the afternoons when your interns are making phonecalls and arranging for things to get done, go spend time with your patients and their charts.

The other thing about "not knowing" everything, comes at least in part from you getting there so early. It's one of the most frustrating parts of being the student, but you never get called with the newest events. The interns get that info in checkout and are the first ones to get paged (plus they come in after you, when the AM labs have completed and are fresh). That's just the way it is. By getting there so early BECAUSE you're searching for the newest data, you end up being put at a disadvantage because it's not there yet...an unfortunate catch-22 to be sure.

 

[TopSecret]

I'm a little confused about SOAP notes (I'm on medicine)...

I get in at 5 am to see my patients, look up their labs, and write my SOAP note before the intern and resident get in at 7 am. Then we all meet at 8 am for work rounds. 10 am is attending rounds.

My question is should I be updating my SOAP note with addendums that include pertinent labs that come up later in the day and changes in assessment and plan if I was totally off with my first assessment and plan? If so when should I do this? If I do it after work rounds it's more timely, but if I do it after attending rounds it will be the 100% sure plan.

I always thought SOAP notes were for overnight events, not to list every patient lab in the past 24 hrs. I also thought SOAP notes were supposed to show what WE know and think the plan should be, not the actual plan (although if I got it right, that would be nice.)

I ask this because my third year partner in crime doesn't show up until the intern and resident do and writes his notes after work rounds. I'm sure the resident gets mad at him for it, but the attending is probably looking at it saying "wow that's a great discussion and plan" without looking at the time it was done. I'm afraid it's making me look bad. Then he updates his note with like 2 or 3 addendums for small changes in plan and what I think to be inconsequential lab results. The attending has to sign off on addendums each time, possibly 15 times a day when he has five patients.

Am I the one that looks bad and is doing it wrong or is he? We fight about this a lot, but none of our uppers will give us a straight answer.

As a medical student your notes are meaningless. They're not medicolegal documents. Interns, residents and attendings are all supposed to write their own notes. To be helpful to everyone on the team it's a good idea to have all the data on hand and presented clearly in the note and have the medications listed as well. The assessment and plan should also be in agreement with the intern and resident. Usually the intern is supposed to help with that part of the note so the chart won't be loaded with all sorts of fictitious plans and addenda that would confuse other health care professionals reviewing the chart.

 

[TopSecret]

I honestly didn't think that the SOAP note was mainly for the student's learning, until I was told that, at some schools, students aren't even allowed to put their SOAP notes in the chart! They have to carry them around until the intern has a chance to review them and offer feedback, and then they are discarded. Sucks, and a bad policy (in my opinion).

Sure, of course you're concerned with what your attending has to say when he reads your SOAP notes. That's normal, and that's one of the reasons why, as a med student, you SHOULD work hard on your SOAP note. (The other being that it's good practice for residency.)

But you don't have to fix the assessment and plan AFTER your attending has critiqued them. It's not that big of a deal.

Leaving out student notes from the patient's chart and then destroying them after the attending reviews them is actually a good idea. It makes more sense than to have fictitious or incorrect impressions and plans written all over the chart.

 

[TopSecret]

Also, all medical students should be aware of the Medicare documentation guidelines.

Google 1997 evaluation and management documentation guidelines to download the manual. You'll be way ahead of everyone else in this regard.

 

[sprinkibrio]

It's so funny how the schedules and expectations at different schools are so different. It makes me concerned about my plan to rotate away next year! I now know my school's expectations now, but hopefully this advice will help others down the road. Btw, don't any of you have computerized charts?!

 

[TopSecret]

It's so funny how the schedules and expectations at different schools are so different. Some of the advice is becoming so school-specific, now that I know how things really work at my school (it's been 4 weeks) that the advice is no longer helpful! It makes me concerned about my plan to rotate away next year! Btw, don't any of you have computerized charts?!

Computerized charts like at the VA are good. Interns and residents can edit the students' notes before they're made viewable to everyone else and made permanent.

 

[TopSecret]

As an attending it's a good idea that all notes be reviewed by someone licensed to practice medicine before it's placed in the chart. I'd be kind of anxious if I were the attending on rounds and a student started questioning my assessment or plan, writing all sorts of incorrect physical exam findings and laying blame on other licensed providers or perhaps the patient, too.

 

[TopSecret]

When I was a resident, I actually sat down with the student to go over the data, impression and plan together and then have the student basically act as a scribe. After the note is in the chart I would then place in the chart my own complete note which would be in agreement with the student's. Residents who write short notes like "agree with the above student note" and barely anything else afterwards are not doing their job.

 

[Substance]

This is but one example of why inpatient "team" medicine is teh sux.

SOAP notes are so inconsistent, and there are too many residents and attendings that want things done in arbitrary specific ways, and who get all huffy if you don't follow suit. It's like Goldilocks!

But if you're a medical student, just do it the way they want you to do it, and then avoid inpatient medicine completely in your career.

It's not the patients that are the problem on inpatient wards. It's everyone else.

 

[perilou]

It's so funny how the schedules and expectations at different schools are so different. It makes me concerned about my plan to rotate away next year! I now know my school's expectations now, but hopefully this advice will help others down the road. Btw, don't any of you have computerized charts?!

Spink, can I have the initials of your partner in crime? 🙂

And, for what its worth, I've been coming in at the same time as you, and it takes me ~45mins/patient.

 

[sprinkibrio]

double post

 

[sprinkibrio]

Spink, can I have the initials of your partner in crime? 🙂

And, for what its worth, I've been coming in at the same time as you, and it takes me ~45mins/patient.

It's not you, I can say that. It may or may not be a male, actually. Sigh. Really, though, I never tried to make this person sound bad, we just do things differently.

 

[perilou]

It may or may not be a male, actually.

Well, those are the two options

 

[drmel]

is it appropriate to look up stuff when writing your soap note to add to your ddx? or is this "cheating"?

 

[a winner is you]

I think it just depends on how your service is. My service right now is a consult service and my progress notes each day are the ONLY notes in the chart from our department. Therefore, I may begin my note before attending rounds, but I only fill in the plan after rounds so that I have the right info for the resident to co-sign underneath my note, since there is rarely a separate resident or attending note.

 

[sprinkibrio]

is it appropriate to look up stuff when writing your soap note to add to your ddx? or is this "cheating"?

I think I was the third year that showed you up the other day.

 

[Doctor Bagel]

Hmm, I guess IM is really different depending on the program you're at. I generally showed up at 7 to round on 4 patients by morning report at 9. Then we'd do attending rounds. We didn't do team work rounds before attending rounds, but the patients were all rounded on by the med student, intern and senior by 9. It took me 30 minutes to round on a patient and write a note because the med student notes were expected to be the most comprehensive notes in the chart. Mine were usually 2 pages, and I was expected to include any new labs or imaging results. Our patients normally had 10+ problems in the A/P, and you have to address all those in the IM notes, unlike surgery notes where you just write about what you're particularly seeing the patient for. We came up with our A/P before consulting with the intern but would normally consult with them before presenting. I never edited my note afterwards because the student note isn't being used for anything other than for your learning (and for residents to easily look at lab values, etc., without having to log into the computers).

As far as timing goes, if you're expected to do everything we were expected to do, I think 30 to even 45 minutes for a new patient is reasonable. On other services where the notes are shorter (surgery and ob/gyn), 30 minutes is definitely way too long. One thing that can help to improve speed is to write most of the note before seeing the patient. Leave a space for the subject and PE and fill in the rest.

As for the comment about not putting notes in the chart, I hated rotating at places like that and luckily that was not the rule at all our core hospitals. I really don't feel like a valued member of the team at all if I can't even place my note in the chart. My understanding is that the student note is discoverable, but I don't think the treatment recommended by the student is used to determine what type of care was actually given.

 

[smq123]

My understanding is that the student note is discoverable, but I don't think the treatment recommended by the student is used to determine what type of care was actually given.

We were told at intern orientation that student notes are not legally considered a real part of the patient's chart, so just signing off underneath the student's name is not acceptable. I think that interns have to document their own physical exams as well.

This may be region or even hospital dependent.

 

[abbottje]

I just finished med service as well and when I didnt update the SOAP notes it would be looked down upon. Actually you dont really need to go back to every single chart and update until you go back to that chart with the attending or senior resident, but before you meet with your seniors you should run and access a computer and quickly look up and pending labs or studies or even make a quick phone call to lab or radiology so that as you present you can present the most current information even if it not written in the note (since the note was written hours prior). And when you are back to the chart with the attending or senior you can always sribble in a little change to your note whether it be labs, imaging, or your assessment/plan. This is what I have found to be the "way" because they always want to be presented with the most current information not just the overnight happenings.... hope that may help....