consult recs in progress note

[albe]

Let's say I'm writing a progress note this morning and a service I consulted yesterday left recommendations last evening. Where should I address their recs in my SOAP note? Would it be under the Objective section, i.e.

S:

O:
Vitals:
Physical Exam:
Labs:
Imaging studies:
Consult recs: Heme-onc team recommends obtaining bone marrow aspirate and biopsy as well as Vancomycin per pt's mucositis

A/P:

Or would I put it under my A/P section, i.e.

S:

O:

A/P:
1. Per Heme-Onc recs, we will obtain bone marrow aspirate and biopsy and begin Vancomycin due to pt's mucositis.



I've looked online as well as First Aid for Wards and Nerd's Guide to Prerounding but I haven't found an answer for this. Any suggestions would be appreciated.

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[SouthernSurgeon]

Let's say I'm writing a progress note this morning and a service I consulted yesterday left recommendations last evening. Where should I address their recs in my SOAP note? Would it be under the Objective section, i.e.

S:

O:
Vitals:
Physical Exam:
Labs:
Imaging studies:
Consult recs: Heme-onc team recommends obtaining bone marrow aspirate and biopsy as well as Vancomycin per pt's mucositis

A/P:

Or would I put it under my A/P section, i.e.

S:

O:

A/P:
1. Per Heme-Onc recs, we will obtain bone marrow aspirate and biopsy and begin Vancomycin due to pt's mucositis.



I've looked online as well as First Aid for Wards and Nerd's Guide to Prerounding but I haven't found an answer for this. Any suggestions would be appreciated.

I would definitely not put it under "O"...

what I would probably put is under "S" for 24 hour events that heme/onc saw the patient. Then under "A/P" put what the actual recs are.

 

[cpants]

I would definitely not put it under "O"...

what I would probably put is under "S" for 24 hour events that heme/onc saw the patient. Then under "A/P" put what the actual recs are.

Exactly. Under S "Heme/Onc saw the patient yesterday and recommended XYZ". Then under A/P put what you will do based on their recommendations (or if you aren't following their recommendation why not).

 

[J1515]

Exactly. Under S "Heme/Onc saw the patient yesterday and recommended XYZ". Then under A/P put what you will do based on their recommendations (or if you aren't following their recommendation why not).

Just put it under the assessment/plan. Something along the lines of "seen by Hem/Onc yesterday - followed by Dr. xxxx" You can even put a pager/contact number in parentheses so others reading the note know who to contact. Never put recommendations or treatment plans anywhere else.

 

[cpants]

Just put it under the assessment/plan. Something along the lines of "seen by Hem/Onc yesterday - followed by Dr. xxxx" You can even put a pager/contact number in parentheses so others reading the note know who to contact. Never put recommendations or treatment plans anywhere else.

Not true. Other team consults and recommendations go under the subjective section, not A/P.

 

[J1515]

Not true. Other team consults and recommendations go under the subjective section, not A/P.

Not sure who taught you that, but you're 100% incorrect and you will get reemed by the attending for putting that under the subjective section. "Subjective" is information you get from the patient or nursing staff including overnight events, recent bowl movements, any current complaints, tolerating diet, etc... Never put a treatment, plan, or recommendations under the "S" in your soap note.

 

[FutureInternist]

I would put it under A/P as well.

1) TTP - Per Hem/Onc continue pheresis every other day till plts > 150, LDH normal......

2) UGIB - Seen by GI. EGD scheduled for this afternoon...

 

[cpants]

It counts as a 24 hour event/update on the patient's treatment and should be included in the S.

example:
In the S: "Pt seen yesterday by urology who recommended a UA and culture."
In the A/P: "UA and culture per urology recommendations"

I was taught to do it that way, and I have never been reamed out by anyone for it because it makes good sense to comment on what consults have been done in the subjective section.

 

[SouthernSurgeon]

Not sure who taught you that, but you're 100% incorrect and you will get reemed by the attending for putting that under the subjective section. "Subjective" is information you get from the patient or nursing staff including overnight events, recent bowl movements, any current complaints, tolerating diet, etc... Never put a treatment, plan, or recommendations under the "S" in your soap note.

As cpants said above, I was taught that "subjective" is the section for any pertinent 24 hour events and I will typically write in things along those lines - "pt seen by heme/onc yest" or "pt underwent EGD for UGIB yest"

The actual "plan" part of a consult team's recs would then go under the A/P.

 

[J1515]

It counts as a 24 hour event/update on the patient's treatment and should be included in the S.

example:
In the S: "Pt seen yesterday by urology who recommended a UA and culture."
In the A/P: "UA and culture per urology recommendations"

I was taught to do it that way, and I have never been reamed out by anyone for it because it makes good sense to comment on what consults have been done in the subjective section.

Do as you wish. You will eventually get yelled at for putting a plan in the subjective section and when the resident or attending corrects you, it's in your best interest to not put up a fight.

 

[THP]

Put it under A/P because it is neither subjective (related to the patient's experience) or objective data. Also the only thing anyone actually reads is vital signs including I/O and A/P.

 

[J1515]

Put it under A/P because it is neither subjective (related to the patient's experience) or objective data. Also the only thing anyone actually reads is vital signs including I/O and A/P.

Shhhhhhhhhh, med students know more than the residents 😀

 

[Twitch]

Pt seen by <service name>. Appreciate recs.

Don't forget the last part.

 

[lord_jeebus]

99% of the time the consult question is that of assessment (eg. is the patient's problem due to CHF exacerbation?) or plan (eg. does the patient need a cardiac cath?). Correspondingly, I would suggest putting your acknowledgement (or refutation) of consultant recommendations in the A/P section.

 

[45408]

Pt seen by <service name>. Appreciate recs.

Don't forget the last part.

that's more important in the private world when you want them to give you a consult in return. In academics, it's a bit less important to be scratching everyone else's backs.

 

[Twitch]

Even more so in academics. It's less about back scratching and more about consult etiquette which goes both ways (b/w consulted service and requester and the other way around) . If you are consulted you should add similar remarks - thank you for allowing us to consult on this interesting case. 👍

 

[DickyV]

Why would you put the fact that a consult occurred under a "subjective" heading? The only way this is subjective information is if you're on a psych ward and the patient states that he hallucinated a GI doc stopping by last night.

I have never seen consult recommendations placed anywhere besides A/P.

 

[VMSmith]

The only reason to mention it in the S: section is if the patient said something about the consultation.

S: Pt stated that he did not want to proceed with the biopsy recommended by surgery consult.
O:...
A/P:
1. Surgery recommended biopsy, however patient is refusing. Appreciate surgery input.

 

[Disinence2]

Plan
1) "Appreciate Consult input"
2) CPM

 

[ACSurgeon]

I would put it under A/P as well.

1) TTP - Per Hem/Onc continue pheresis every other day till plts > 150, LDH normal......

2) UGIB - Seen by GI. EGD scheduled for this afternoon...

Perfect example. Of course as a student, I'd go through the entire BS of saying what the status of the pt's TTP, what he's currently on, and what our plan for that day is, which would most likely by taking the recs of heme/onc.