SOAP note

Discussion in 'Medical Students - MD' started by MS05', Feb 26, 2002.

  1. MS05'

    MS05' Senior Member

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    Anyone know where you can find a good example of a SOAP note on the net? Thanks!
     
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  3. Winged Scapula

    Winged Scapula Cougariffic!
    Staff Member Administrator Physician Faculty Lifetime Donor Classifieds Approved

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    No, but here's one I wrote this morning (I'll leave it to you to figure out the abbreviations)....

    S: (I don't really label, the S and O, but what the heck): no acute events o/n; patient without c/o

    O: Tm 37.8 Tc 36.6 82 20 118/64 98% RA I/O: 3200/2750 JP #1 20 #2 15 Rectal tube 500 NGT 500

    CNS: A&O, NAD
    Cor: RRR No M/R/G
    Pulm: LCTAB ISB to 2500
    GI: O/S/NT/ND/NABS Stoma pink and active; stool and gas in ostomy
    GU: Foley with clear yellow urine
    Ext: No C/C/E

    A/P: 72 yo WF s/p IPAA POD #3
    AVSS
    Doing well
    Advance diet to clears ad lib
    CCM per pathway
     
  4. Castro Viejo

    Castro Viejo Papa Clot Buster

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    Kim, that's already a pretty long note from SURGERY! :)

    The absolute coolest note I've ever seen from Surgery was:

    Surg Att Note

    Pt seen. VSS. Doing well.

    HJ

    :D
     
  5. NuMD97

    NuMD97 Senior Member

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    There is a plethora of data on the web about SOAP notes. Keep in mind that the notes will vary somewhat depending on specialty: surgical SOAP, medical SOAP, OB/GYN SOAP, vs. Peds SOAP.

    Here's some examples I found doing a rapid search of the Net:

    <a href="http://cpmcnet.columbia.edu/dept/ps/2002/SOAPintro.html" target="_blank">http://cpmcnet.columbia.edu/dept/ps/2002/SOAPintro.html</a>

    <a href="http://www.google.com/search?hl=en&q=medical+soap+notes" target="_blank">http://www.google.com/search?hl=en&q=medical+soap+notes</a>

    <a href="http://cpmcnet.columbia.edu/dept/ps/2002/SOAPmed.html" target="_blank">http://cpmcnet.columbia.edu/dept/ps/2002/SOAPmed.html</a>

    I hope this is of some help to you. Good luck! :)

    Nu
     
  6. Winged Scapula

    Winged Scapula Cougariffic!
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    </font><blockquote><font size="1" face="Verdana, Helvetica, sans-serif">quote:</font><hr /><font size="2" face="Verdana, Helvetica, sans-serif">Originally posted by Timothy Wu:
    <strong>Kim, that's already a pretty long note from SURGERY! :)

    The absolute coolest note I've ever seen from Surgery was:

    Surg Att Note

    Pt seen. VSS. Doing well.

    HJ

    :D </strong></font><hr /></blockquote><font size="2" face="Verdana, Helvetica, sans-serif">Yeah - I even left out a couple of comments (ie, Incision C/D/I, well approximated, surgi-staples in situ).

    I've also seen attending notes along the same lines as you have. Always amuses me too. Anything to check off that box on the billing sheet, eh? :D
     
  7. The best one I've seen (by an orthopod):

    Comfortable. Afebrile.
     
  8. tussy

    tussy Senior Member

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    There is a famous story at my school about a progress note written by a senior urology resident. It goes as follows:

    Patient in V.fib
    Code in progress
    No active urological issues
     
  9. dr.evil

    dr.evil Senior Member
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    Classic note from an attending on surgery only said this:

    diarrhea

    We laughed for days on that note.
     
  10. MS05'

    MS05' Senior Member

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    Thanks NuMD97 and others...much appreciated!
     
  11. neutropeniaboy

    neutropeniaboy Blasted ENT Attending

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    </font><blockquote><font size="1" face="Verdana, Helvetica, sans-serif">quote:</font><hr /><font size="2" face="Verdana, Helvetica, sans-serif">Originally posted by LionTrees:
    <strong>Classic note from an attending on surgery only said this:

    diarrhea

    We laughed for days on that note.</strong></font><hr /></blockquote><font size="2" face="Verdana, Helvetica, sans-serif">Ahhhh...doing the very least possible in order to cover your legal butt and bill at the same time.... :D
     
  12. mdjmd

    mdjmd Junior Member

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    How bout this one--
    When rounding on gen surg, the attending always asked, "Fever?" When no one answered in the affirmative, he would leave for the day.
     

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