SOAP note

[MS05']

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

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[Winged Scapula]

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

 

[Castro Viejo]

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

 

[NuMD97]

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

 

[Winged Scapula]

•••quote:•••Originally posted by ******:
•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

•••••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?

 

[endo]

The best one I've seen (by an orthopod):

Comfortable. Afebrile.

 

[tussy]

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

 

[dr.evil]

Classic note from an attending on surgery only said this:

diarrhea

We laughed for days on that note.

 

[MS05']

Thanks NuMD97 and others...much appreciated!

 

[neutropeniaboy]

•••quote:•••Originally posted by LionTrees:
•Classic note from an attending on surgery only said this:

diarrhea

We laughed for days on that note.•••••Ahhhh...doing the very least possible in order to cover your legal butt and bill at the same time....

 

[mdjmd]

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.