SOAP note advise

[KEJ]

I need help with writing SOAP notes... I know how to do them, but the program I attend requires that we get the soap note written within 9 mins (I know this is required for the board exam). I can't seem to get past the very beginning of the objective portion before running out of time. They require our subjective section to be very extensive, and we are typing it out from scratch... no check boxes or template is given.

what can i do to improve so that i am not running out of time, and submitting incomplete soap notes??

Please Help!

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[Chibucks15]

I need help with writing SOAP notes... I know how to do them, but the program I attend requires that we get the soap note written within 9 mins (I know this is required for the board exam). I can't seem to get past the very beginning of the objective portion before running out of time. They require our subjective section to be very extensive, and we are typing it out from scratch... no check boxes or template is given.

what can i do to improve so that i am not running out of time, and submitting incomplete soap notes??

Please Help!

This is gonna sound revolutionary, idk if you've been told this before, but just sit down and practice more? That's literally it

 

[deleted1079620]

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[Neopolymath]

On BS things like the PE and whatever things your school does to prepare you for it just write your SOAP note backwards. Fill A/P and then objective (but don't go wild, just cover bases to check boxes) and then make your S as good as time allows.

These PE training things are nothing like real life so don't treat them like real life. Students tend to start out getting bogged down in the subjective on these timed note writing sessions and they waste time. Also don't fix typos if you aren't a fast typer until you get done with stuff. You are likely wasting a ton of time on the S and typos for no reason.

Most of these things are graded as box checking so it's better to have something in all the categories than to have some excellent subjective but nothing else.

 

[ciestar]

Damn... i dont write a real SOAP note in 9 minutes lol

but for real, practicing is the best you can do, unfortunately. Now, i didnt take PE but took CS and how i approached it was the plan piece and worked my way backward. As far as subjective goes, less is more.

 

[BoneWizard]

Are you trying to type in full eloquent sentences?
I kept hitting the time limit for SOAP notes until I realized they don't care how nice it sounds. You just need to have the content there. So I stopped trying to make it sound pretty and fixing typos. My notes read like a 2nd graders English report but it's got all the pertinent content and I stopped running out of time.

 

[KEJ]

Thank yall so much for the suggestions!! I will try working backwards because I definitely get bogged down in the subjective portion!

 

[AlteredScale]

I need help with writing SOAP notes... I know how to do them, but the program I attend requires that we get the soap note written within 9 mins (I know this is required for the board exam). I can't seem to get past the very beginning of the objective portion before running out of time. They require our subjective section to be very extensive, and we are typing it out from scratch... no check boxes or template is given.

what can i do to improve so that i am not running out of time, and submitting incomplete soap notes??

Please Help!

You should have your AP portion memorized for most general complaints like CP, Abn Pain, depression, diarrhea.

 

[Spectreman]

Yep, truly, the secret for Comlex PE is to write your note backwards. Do the A/P first because each section carries the same weight in terms of grade, so you crank those out first and make them pretty, then you blast the vitals and relevant objective, the pertinent negatives you get comfortable typing super fast, then you do as much subjective as you can before time runs out.

 

[Espressso]

+2 to those who said start with A/P. Literally the first things you should type are the 5-7 differential diagnoses and then immediately type out your plan. Then quickly do the PE. the PE should be relatively memorized, you want to have a good PE backbone you can do on everyone and also type out easily. last section is the HPI/subjective portion since that is the most bs

 

[SLC]

S = subjective. The stuff the patient tells you. Use the OLDCARTS mnemonic, it gets you the info you should need. It also gets you the info you need for a reimbursable patient encounter later in your career. I legit have the OLDCARTS thing saved as a quick text and I add it to every note. The pitfall with subjective that I see with students (and probably fell victim to as a student) is getting bogged down in non-crucial details. Getting too much subjective info is usually not helpful and can derail a presentation to your attending or resident pretty quickly. When I address a complaint, I want to know roughly how long it’s been going on. When a patient starts to go off on how “my daughters birthday was 3 weeks ago and I think it was 6 maybe 7 days before that” I instantly write “~1month” and move on. Whether it started on the 9th or the 16th is rarely of any clinical importance. Which family member had symptoms is also rarely more useful than “sick contact - family member”. Just stick to what helps you get a sense of what’s going on. You can fold a clinically pertinent ROS into this as well.

O = Objective. I.e. what you figure out on your own. Vitals, physical exam, POC testing. If it’s data you collect in real time that informs your assessment (diagnosis) it goes here.

A = Assessment. A concise statement summarizing the above info and stating your working diagnosis. Something along the lines of (for example) “22yo female with no significant PMHx here today with 6 days of non productive cough, subjective dyspnea, fever, and anosmia which occurs in the context of a known SARS-CoV-2 exposure. Exam significant for clear lungs, no post nasal drip, fever to 101.8F and SpO2 of 95% on room air. Clinically she has SARS-CoV-2. Differential includes: non-specific viral URI, RAD, etc etc.

P = Plan. What you intend to do with the patient. In other words, further testing (if needed), treatment, and contingencies if any further work-up leads you to needing to switch your diagnosis, ED referral, whatever you’re going to do about the patient, it goes in plan. It’s good if you know why you’re ordering tests you’re ordering. In the real world I often write a snippet about the rationale for each test, so when results come in I can go back and remember what I was thinking. But I see 25 people a day and it gets hard to keep everything straight when I’ve got a bunch of labs to review 2 days later.

Also in the case of problems that require regular follow up I write next steps here.


But the key is conciseness and avoiding extraneous info that doesn’t inform an assessment and plan.

and I agree with the folks that say write the A/P first. In fact, my EMR notes are set to have the A/P at the top of each note; because in the real world, that’s what I need to read when I come back to the patient later.

Does that make sense?

 

[deleted1082375]

Get your mnemonics down for OLDCARTS, med history, and personal history. Tune it down to only what you need. Get rid of stupid crap like military history. Write them on the clipboard before you go in to the exam room. Cross them off if you need to as you ask the questions. Don't write **** on the clipboard except for the meds the patient takes or anything else weird. You're in med school and should be able to remember easy stuff for 10 minutes with little to no effort. Get out of the room as fast as possible while hitting all your bases. ALWAYS HEART AND LUNGS. ALWAYS DRAPE. Go in and practice moving the table around and learning the layout of the room a couple of days before if you can.

Actually practice typing notes and home. Look at example soap notes posted online. You will improve with time.

 

[Spectreman]

I did CODIERS SMASHFM because that’s how the Kaufman videos do it.
FYI: I totally BS’d my way through this stuff, watched the Kaufman videos in the hotel literally the night before my test. Wrote practice soaps on each of the cases (I think there are like 12?) and then read what they put in Kaufman. Passed the thing with zero issue.

 

[deleted645092]

Pt info:

HPI:

ROS:

PHx:

SurgHx:

FHx:

SocHx:

Allergies:

Meds:

PE:

Assessment:

Plan:

Signature:

Take the above template and practice writing it down over and over til you have it memorized cold. When actually writing notes try and use shorthand as much as possible but only for things that take less time/ are easier than writing out the full words. Like for me putting in HTN actually takes longer than hypertension on a keyboard.

Outside of those two pieces of advice it really is just practice over and over.

 

[Isoval]

Lol it takes me thirty minutes to write a real H&P for a new admission (inpatient IM), maybe longer if the patient is a dumpsterfire. Hard to tell in Family because I wrote my notes mostly in real-time while talking to the patients.

As far as school is concerned, I did the following for my standardized patients:
- most of your points are going to come from your S and O sections, or at least that's true for TCOM. These sections are also the sections which require the most writing, and likewise, should have the lion's share of your time.
- for S, I write down the list I've kept in my head of pertinent information. First paragraph of a few sentences: "Patient is a ____ presenting today for _____ pain in _____ of _____ days duration. They state this pain is entirely new to them, nothing makes it better or worse, and it is described as a dull, throbbing pain. The patient thinks it's due to ______." Next, bullet out your medical and social review. "Patient is on ___. Patient has no allergies. Patient has no surgeries. Patient has no hospitalizations. Patient is adopted and has no known family history. Patient has no known medical history. Patient has a diet consisting primarily of fast food, but occasionally cooks home meals heavy in carbohydrates. Patient does not exercise. Patient does not drink." etc.
- for O, begin with vitals, then give a brief description from head to toe, beginning with general appearance and their mentation status. "BP 140/80, P 80, T 98.8, BMI 26, O2 98, R 14". "Mentation normal, gait normal, patient appears in pain but otherwise well and in no acute distress". "HEENT reveals _____". "Chest CTAB". "Heart RRR, no gallops, rubs, or murmurs". etc.
- after this, you should have used a vast majority of your time. That's normal. For A, just write down a numbered list with their CC at the top: "1. Right shoulder pain. a) Rotator cuff tear b) rotator cuff sprain c) overuse syndrome" then move down to the BS they like to see where you present non-CC diagnoses "2. Hypertension 3. Depression". A is done, and it should have taken you thirty seconds.
- for R, I like to write assessment-oriented recommendations. For example:
"#Right shoulder pain due to rotator cuff tear
- ultrasound ordered to verify diagnosis
- ketorolac prescribed for pain control PRN
- RICE therapy was recommended to patient
- patient advised to avoid using R arm for 1 week
- f/u 4 weeks"
And do that for all diagnoses.

 

[CocoMelon0531]

Look up the NBOME for all approved shorthands. Incorporate those letters into muscle memory for your first two years of med school. You will thank me for it.

 

[group_theory]

Just be glad you don't have to handwrite your SOAP notes (and making sure it is legible for the grader to read) - imagine having to hand write all those SOAP notes for the COMLEX PE (when did it go from paper SOAP to EMR?)

OR you can just do a ortho soap note

S: Patient fell, thinks he broke his hip
Family History: non-application
Allergy/Meds: defer to medicine
O: R femoral neck fracture on X-ray
A/P: ORIF R femoral neck, medicine consult for medical management

 

[Calizboosted76]

Man reading through these responses, seeing what I have to look forward to and all I can say is that I am glad I have been a scribe for the past three years.

 

[butidontwantto]

I was also a scribe for 3 years, and in some ways it helps, and in others it gets in the way. Just be prepared to unlearn habits that were fine in clinic but that don't work when you're being graded in a very specific way. (I'm not still grumpy that NBOME decided you can't abbreviate nausea/vomiting/diarrhea with n/v/d what are you talking about).

 

[deleted1082375]

Man reading through these responses, seeing what I have to look forward to and all I can say is that I am glad I have been a scribe for the past three years.

Won't help much. It's much harder asking the questions, doing the exam, and synthesizing differentials and plans instead of just writing them down and relying on macros and the medical knowledge of the attending to get the note done.

 

[Calizboosted76]

Won't help much. It's much harder asking the questions, doing the exam, and synthesizing differentials and plans instead of just writing them down and relying on macros and the medical knowledge of the attending to get the note done.

I was also a scribe for 3 years, and in some ways it helps, and in others it gets in the way. Just be prepared to unlearn habits that were fine in clinic but that don't work when you're being graded in a very specific way. (I'm not still grumpy that NBOME decided you can't abbreviate nausea/vomiting/diarrhea with n/v/d what are you talking about).

I was more or less talking in regards to my typing speed, lol.

 

[deleted1082375]

I was more or less talking in regards to my typing speed, lol.

you can just learn that **** from roasting normies online. reeeeeeee

 

[Redpancreas]

I need help with writing SOAP notes... I know how to do them, but the program I attend requires that we get the soap note written within 9 mins (I know this is required for the board exam). I can't seem to get past the very beginning of the objective portion before running out of time. They require our subjective section to be very extensive, and we are typing it out from scratch... no check boxes or template is given.

what can i do to improve so that i am not running out of time, and submitting incomplete soap notes??

Please Help!

I second the point about practice. The templates other's have posted are good starting points. One thing that will help you greatly not only now, but moving to residency and beyond is to streamline your

1) mental clinical reasoning
2) how you document
3) how you report.

Medicine is very nuanced and every word matters For example when describing a fall its important to get in a habit of specifying whether it was "mechanical" or when describing weight loss characterize it as "intentional" vs "unintentional". Get in a habit of reasoning, documenting, and reporting the same way. This will save you a lot of time and make your work quicker and error free.

The big delay you're experiencing is because you have no framework and every time you write a note, your mind is trying to reinvent the wheel. Invest a few weeks (you'll need time to make it work for you) creating your own framework for the SOAP note. Start with something like what you see above and type things the same way each time. Get in the habit of having "abdomen soft, non-tender, non-distended" roll off your finger tips. I know there are templates/shortcuts that get unlocked in residency BUT if you get good enough now, typing free-hand will actually be more efficient and save you the hassle of all the mistakes those templates will set you up for in residency.

Without going into detail here is the framework of the SOAP:

Subjective (I will use the example of headache)
1.) Age, Sex, Chief Complaint-("headache")
2.) HPI - onset, what makes better/worse, quality, radiation, severity, temporal, associations
3.) PERTINENT ROS. Invest the time now to have 10-20 ROS questions memorized. It sounds intense but it will pay dividends when these rattle off your tongue during the interview/presentation as well as off your fingertips when typing your note. Bad trainees document inaccurate ROS by leaving the template untouched, acceptable trainees leave the template but delete many things they don't ask, excellent trainees streamline their exam and documentation so every word in their ROS is accurate based on interview. If you invest time striving for excellence now, it will only become faster/easier as you progress.

Objective:
4.) Physical Exam. Similar concepts to ROS above, use one template for inpatient H&P, another for outpatient H&P, and another for interval exam. Please don't forget vitals.
5.) Basic Labs/Imaging: CMP, CBC, Urine as well as whatever the ED or OSCE scenario is giving you.

Assessment:
Age, Sex, Chief Concern (acute onset bilateral headache associated with vision changes and whatever HPI, ROS, History is immediately relevant), hemodynamically stable in no distress without focal neurological deficit with pertinent lab findings of XYZ.

From here on there are two ways of doing it. You can say differential includes, A, B, and C and then give a plan with bullet points OR you can go problem based which is more translatable to residency where patients aren't coming in for one thing unlike on an OSCE.

You will have success with this method.

 

[KEJ]

Thank you for all the suggestions!! I will be putting them to use!

 

[Redpancreas]

Thank you for all the suggestions!! I will be putting them to use!

I'm willing to review your template when you make it. Post it on here and let's see how it looks.