MS2...struggle with SOAP notes

[ULTRA nerves]

Hi all. I am a MS2 now and taking SOAP notes has been the biggest challenge lately. I was volunteering at a free-clinic other day and realized that my SOAP note taking skills and presenting cases in front of the attending is really bad when compared with my classmates. I mean...attendings look confused when I present & they sigh when the read my soap notes. What do I need to do to improve? I realize that they are rather acquired skills and perhaps get better with practice but I have been to clinics as many times as others in my class. Is there something I am not doing and others do?

Also, I am an introvert and soft spoken. I guess because of my quietness people think that they need to explain things that I already know...perhaps I don't act like I know them...or maybe I don't know as well as others do. I am afraid that I am digging my own grave and that if I don't change what I am doing I will be in BIG trouble when the rotations come. Can you help me, please? How do I get over the fear of presenting in front of an attending and how do I get a better handle at organizing my thoughts? Is there a system that I can use? (I use OPPPQRRST...but not much after that.)

If people out there went through similar experience, please share and save this poor soul. Thanks a bunch!

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[lord_jeebus]

It might help if you posted an example of a SOAP note you would write on a fictional patient. Then we could give you concrete feedback.

 

[fakin' the funk]

You're an MS2. You're new to it. It takes practice. You'll get better. Relax.

 

[Terpskins99]

Not by any stretch of the imagination... but here are some tips that I've picked up.

1. Make it concise and to the point. I prefer PPQRSTA, but I rarely ever write all of them down... only whatever facts feel relevant.
2. Always address the chief complaint first.
3. Follow a formula and don't stray from it. Lots of books that can help with this. A nice one that'll help with boards (the physical exam portion) are USMLE Step 2 CS review books. They always have great tips for writing out H/P's.
4. Use as many of the universal abbreviations as possible. CP = chest pain, c/c/e for clubbing/cyanosis/edema... etc.

As for presenting a patient... again, use a formula.
mine usually goes something like this:
patient name, age, chief complaint, BRIEF history of present illness, RELEVANT patient history (if you think pt has cancer, does family have cancer?... etc), RELEVANT physical exam findings/lab findings, your diagnosis, your plan of action.

A lot of this is just practice. Everybody feels lost on the floors to some extent, its natural. Easiest way to learn, just watch what the others do and follow their example.

 

[LadyGrey]

You said you're in an outpatient setting, so I'm not sure how much this applies, but look at the previous note(s) in the chart, especially ones by medicine interns and residents since they still tend to be thorough and legible. (Actual surgery progress note I saw the other day: "Much better." That was all he wrote).

Do you have any interns, MSIVs, or MSIIIs there that you can ask for help? They might be more willing than an attending to go through your note and give concrete advice.

 

[McSnappy]

To start, your interview is key: You need to think by system and then have an idea of what could be wrong by what they tell you.

S: subjective - Chief complaint..i.e., who the patient is and why they are here. subjective meaning what the patient has to say. It is subject to her interpretation. (ex. 22 yo G0P0 (on fertile women--know this hx) WF with a Hx of asthma presents with difficulty breathing/SOA. Then talk/write about how the patient got where there are today. ex. Pt has had asthma for 16 years and reports she was out running last night when she become SOA. She reportedly has used her albuterol inhaler, 2 puffs, Q2-3 hours for the past 8 hours prior to coming to the clinic. Her last inhaler use was just a few minutes ago in the waiting room. (Remember...at a clinic..they need to see several patients, so keep it succinct and to the point). Then run thru a pertinant ROS by system: Pt reports Headache, no loss of vision, denies chest pain, patient says she has a dry cough with no muccous production, denies N/V/D (nausea, vomiting and diarrhea), had a UTI last month that resolved with bactrim Abx., is sexually active with one partner for past 2 years, rest of ROS was non-contributory. She has NKDA. Her current medication is only albuterol. She denies using Etoh, drugs.

Side note: I usually put her medications w/ dosages in a list to the left side of the note in a running column with a one word of what it is used for.

O: objective - This is what you find out is physically wrong/right with the patient. This is where a lot of attendings like things differently. Some like you to put things in systems with relevant vitals and labs within each system with trending of labs and vitals or highs and lows, etc. and some like you to put vitals on a line, labs underneath and then start physical exam by system. So, find out how they like it and do that. Personally, I like the latter with trends of labs and vitals. Now, when I present the info, I give all the vitals, then with labs, I pull out the relevants and give those. Like, with patient above. (Her last labs were 4 weeks ago and revealed her Hgb was 10.5 and Hct was 41. Today her Hgb is 10.1 and her Hct is 40. She was slightly hyperkalemic...etc. Remember, you are painting a picture of where they were and who they are today, based on the info you have.
Then do a physical exam by system. (I like head to toe approach in all systems). General, HEENT, CV, Resp., GI, GU, Ext. (musculoskeletal, neurologic).
A: Assessment - Assess the patient. This is where each of the pieces above (S.O.) should be reflected to start narrowing the patient into a diagnosis. Some attendings want this by system also...esp. internists
ex. Pt. is a 22 WF w/ a Hx of asthma presented to the clinic with acute flare of her asthma. Then list out her problems.
1. Asthma: Patient is a long standing asthmatic whose current medication regimine is only albuterol 1-2 puffs q4h PRN. She is not in status asthmaticus. She has mild-moderate persistant asthma.
2. Anemia: Pt does not take PNV (prenatal vitamins), is not pregnant? (did we forget a lab..sh^&%...go back and find this out before presenting or is this part of your plan and has no si/sx of bleeding.
3. Hyperkalemia: believed to be secondary to albuterol use.
P: Plan: -- what is your plan. Have some kind of plan, lay it out there, don't be afraid of looking dumb, 'cause we all are comparably to our attendings and they were there once too. Learn from them and look at notes better than yours (usually the one written right before yours in a chart)
1. Asthma - a. give nebulizer tx with albuterol. b. start prednisone PO x 10d. Begin inhaled corticosteriod for long-term control.
2. Anemia: Patient may be pregnant. check status of Beta-HCG, if negative, do a nutritional assessment and begin ferrous Sulfate PO Qday. F/u in 3 months w/ CBC.
3. Hyperkalemia: f/U in 2 weeks with CBC.
4. HIV, Gon/chlam labs, pregnancy and sexual counseling. (you are in a saftey net clinic right

Now..I didn't put everything in, missed a lot we could have covered, but that should get you going and give you the gist of it. If you cut the garbage I included above, the note is less than 3/4 - 1pg. The best is to do over and over and over and over and over and over...which will happen in your 3rd year.

 

[Tired]

Or make it really simple.

Step 1 - Look at the note from the day before
Step 2 - Copy it, changing the "S" slightly, insert new vitals and labs, and advance the "post-op day" by one

Done!

 

[JayneCobb]

Or make it really simple.

Step 1 - Look at the note from the day before
Step 2 - Copy it, changing the "S" slightly, insert new vitals and labs, and advance the "post-op day" by one

Done!

let me guess. you're either ortho or gas? The point of maximal intensity doesn't exist

to the OP: post an example of your soap note so we can offer suggestions on improvement

 

[jones173]

I am a third year and have found the SOAP series put out by Lippencott I think to be invaluable in both histories and helping to write good SOAPs. Its a little gem, check it out

 

[elwademd]

You're an MS2. You're new to it. It takes practice. You'll get better. Relax.

all you need to tell the attending is:

who's the patient?
why are they here?
what are we going to do for them?

clearly, it's more descriptive and at times more difficult than that, but at it's base, that's what the attending wants to know.

 

[rockit]

A few things that helped me with notes and presentations.

1. Writing full H&P's on admission. When you have to write the whole thing, your presentation gets much better. There's only so much space to tell the story, so you figure out what's important.

2. Your daily note needs to address; why are they here, what are we doing. Surgery is actually a good place to figure this out. Somebody is post-op day x, they feel fine. So your subjective part only says, "pt w/o complaint, no bleeding, eating/drinking/etc...". The real reason they're in the hospital is because they had surgery. There's not a lot to do other than monitor, so your note should reflect that level of concern.

3. Presenting physical exam: let the word "unremarkable" be your friend. If there's nothing wrong with it, don't talk about it.

 

[71263]

When you start out as an M2, you probably started the year without having ever written a SOAP, its no wonder you totally suck ass at it. I did, we all did. Hell, your attendings all probably sucked ass at it when they were M2s. At about halfway through M3 year, Ive gotten to a point where Ive had enough practice that Im mediocre at it, but still pretty bad.

Also, understand that every rotation and every attending has their own style. It will always take you a few days to adjust to that. But by the end of the first week, you should know enough to be able to write exactly what they want from you.