Does anybody know of any good online resources that teach you how to write a presentable SOAP note or progress note?
Thanks.
Thanks.
How to write a proper soap note?
- Thread starter naseeha
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this site has like sample notes for each clerkship:
http://tmedweb.tulane.edu/portal/files/open-access/clinical-diagnosis/SampleSoapNote.pdf
I actually printed out the medicine one and keep it
in my clipboard just to refer to, but after awhile you just get the hang of it and learn what things are important to present and in what order, and what things can basically be left out but referred to if someone asks
http://tmedweb.tulane.edu/portal/files/open-access/clinical-diagnosis/SampleSoapNote.pdf
I actually printed out the medicine one and keep it
in my clipboard just to refer to, but after awhile you just get the hang of it and learn what things are important to present and in what order, and what things can basically be left out but referred to if someone asks
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Look at the resident's soap notes and mimic them.
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Get a Maxwell's pocket reference. It has everything you need to know.
- Joined
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S: Patient seen and examined. Nursing reports restless night. Pt states legs hurt, pain medicine not holding more than 3 hours. Breathing doing better with RTC nebs, no nicotine cravings. Not happy with wound care regimen. Awaiting surgeon assessment today. Still spiking temps.
O: Gen: WD/WN 80 y/o WM AxOx3 in NAD
VS: T 101.2, P 80, R 18, BP 120/70 Pain level 5/10 in legs
Card: Reg Rhythm nl rate S1, S2 no murmurs
Resp: Coarse lung sounds, insp/exp wheeze, green phlegm, + deep cough
Abd: Soft, NT/ND BSx4
Ext: + 3cm x 4cm stasis ulcer RLE lateral side. Green exudate from wound. Surrounding erythema, severe TTP. Rt foot cold to touch. No palpable DP pulse, Toes mottled, deep purple color. Nails thick with fungus, Skin peeling, No pain sensation to palmar surface. LLE normal, no C/C/E. Good pulses. Sensation intact.
Labs: CXR + RLL infitrate with mild pleural effusion
RLE venous/arterial study shows occlusion of the dorsalis pedis
Wound cx +MRSA, sensitive to bactrim, levaquin
Sputum cx: pending
A/P
1. RLL pneumonia: sputum cx pending, Will continue Azithromycin, Levaquin for both resp, wound coverage. CAP protocol in place. O2 to keep sats >92%. Cont Alb/Atr Nebs, Flutter valve at bedside.
2. Rt pleural effusion: cont lasix 10mg IV q 8hrs
3. RLE arterial occlusion: vascular consult pending, await recommendations
4. Rt venous stasis ulcer: Continue wound care per WOCN/PT
5. Rt leg pain: Breakthrough pain, esp at night. Incr Vicodin to q 3 hrs
6. Nicotine addiction: stable nicoderm patch 21mcg
7. HTN: Stable, continue home benicar 20mg
Continue care. Follow PNA with serial xrays, ? surgery this week per vascular. May need long term rehab for wound care, mobility. Discharge planning to look at options once surgeon has determined course of action.
O: Gen: WD/WN 80 y/o WM AxOx3 in NAD
VS: T 101.2, P 80, R 18, BP 120/70 Pain level 5/10 in legs
Card: Reg Rhythm nl rate S1, S2 no murmurs
Resp: Coarse lung sounds, insp/exp wheeze, green phlegm, + deep cough
Abd: Soft, NT/ND BSx4
Ext: + 3cm x 4cm stasis ulcer RLE lateral side. Green exudate from wound. Surrounding erythema, severe TTP. Rt foot cold to touch. No palpable DP pulse, Toes mottled, deep purple color. Nails thick with fungus, Skin peeling, No pain sensation to palmar surface. LLE normal, no C/C/E. Good pulses. Sensation intact.
Labs: CXR + RLL infitrate with mild pleural effusion
RLE venous/arterial study shows occlusion of the dorsalis pedis
Wound cx +MRSA, sensitive to bactrim, levaquin
Sputum cx: pending
A/P
1. RLL pneumonia: sputum cx pending, Will continue Azithromycin, Levaquin for both resp, wound coverage. CAP protocol in place. O2 to keep sats >92%. Cont Alb/Atr Nebs, Flutter valve at bedside.
2. Rt pleural effusion: cont lasix 10mg IV q 8hrs
3. RLE arterial occlusion: vascular consult pending, await recommendations
4. Rt venous stasis ulcer: Continue wound care per WOCN/PT
5. Rt leg pain: Breakthrough pain, esp at night. Incr Vicodin to q 3 hrs
6. Nicotine addiction: stable nicoderm patch 21mcg
7. HTN: Stable, continue home benicar 20mg
Continue care. Follow PNA with serial xrays, ? surgery this week per vascular. May need long term rehab for wound care, mobility. Discharge planning to look at options once surgeon has determined course of action.
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S: Subjective assessment of your patient (i.e. how they are doing at this time in their own words), new issues, basic ROS
O: objective - physical exam, labs, radiology
A/P: Assessment/Plan
assessment = a few lines about why the patient is in the hospital/clinic
plan - a list of each problem in order of importance, the current status of the problem, and you are doing for each problem
Yep that's about it. Promise it isn't that hard once you do a bunch. Get the Maxwell's pocket reference for physical exam stuff. Also ask your residents for help if you have questions. Remember your SOAP note is essentially your presentation and those two things combined are essentially your grade.
O: objective - physical exam, labs, radiology
A/P: Assessment/Plan
assessment = a few lines about why the patient is in the hospital/clinic
plan - a list of each problem in order of importance, the current status of the problem, and you are doing for each problem
Yep that's about it. Promise it isn't that hard once you do a bunch. Get the Maxwell's pocket reference for physical exam stuff. Also ask your residents for help if you have questions. Remember your SOAP note is essentially your presentation and those two things combined are essentially your grade.
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