Doing write-ups

[Cholinergic]

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I'm a second year getting ready for a preceptorship in January. We're expected to write up history and physical stuff but we haven't learned how to do that. Is there a format for doing that? I know nurses use SOAP notes. Do we use that too?

Also, is there a pocket guide that is recommended for the wards?

👍

 

[desertdoc]

Doctors do use SOAP notes. There should be a good example of a write up in your physical exam text book.

 

[Random]

Check out the appropriately named "Write Ups" page at http://medicine.ucsd.edu/clinicalmed/introduction.htm.

 

[AmoryBlaine]

Maxwell's is key. FYI a SOAP note is a progress note, it should follow a more formal "H&P" or "write up" in a chart. SOAPs tell you what happended the day before and what is going to happen today.

 

[Taciturngosamer]

I'm a second year getting ready for a preceptorship in January. We're expected to write up history and physical stuff but we haven't learned how to do that. Is there a format for doing that? I know nurses use SOAP notes. Do we use that too?

Also, is there a pocket guide that is recommended for the wards?

👍

One word: Maxwell's: Pros; You'll actually use it during 3 and 4th years. Its cheap. Its slim. Its got formats for write ups. Its got useful facts. It won't give you neck pain from carrying it around in your white coat. All in all a good choice for the random review before 'pre-rounding' at 5am when my brain most certainly isn't at top speed.

Cons; It isn't a novel. Its a short fact sheet that gives you the basics. If you need to see examples it isn't going to help. It you need more I reccomend Bate's guide to the physical exam for a reference (you will NOT be carrying this around). It has a section on write ups and goes through the whole exam with pertinent findings/special tests. Half of doing a good write up is knowing the most concise clear vocabulary and getting the format down.

Also Medfools.com has a good downloadable outline for notes.

Hope that helps.

 

[Cholinergic]

Thanks.

I have Bates, but I wasn't aware it had a write up section. We've only been reading selected chapters. I'll look at it again. The link is just what I needed. Thanks for recommending Maxwell's. It got good reviews on Amazon.