SOAP notes and H/P advice?

[spacemanspiff]

Hey everyone,

I'm having a hard time standardizing my SOAP notes and H/P write ups...I just want to find the best way to write them and keep using the same style everytime. Does anyone have any sample write ups, links to sample write ups, advice, etc? I greatly appreciate your help!

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[DragonWell]

This might get you started if you haven't checked it out already:
http://medicine.ucsd.edu/clinicalmed/write.htm

 

[bpayh]

I thought the SOAP note, at least, would be easy to keep standardized.

This is how I do mine

Heading (like IM Student, for example)
S
Description of pt. interaction. Pt. complaint, HPI, ROS, etc.
O
vitals
physical exam
I/O's and other pertinent info if necessary
labs
A
1, 2, 3, 4, etc
P
1, 2, 3, 4, etc

I write a med list in the left margin of the note

 

[werd]

i'd recommend (and most people do this) doing A/P together, ie...

A/P: 57yo M hosp. day 4 for (whatever) who... (general statement of how they are doing).

1) renal - low uop and increasing Cr suggest ATN, likely 2 to (whatever); will get U/A daily and CBC q8hr; hydrate with (); will get renal consult today.

2) pain - still c/o moderate pain; con't (whatever) and add (whatever), monitor closely

3/4/5

H&P's usually go something like, CC/HPI/ROS/PMH/FH/SH/Meds/Allergies/Immunizations/PE/Labs/A+P

 

[AF_PedsBoy]

I agree with the A/P being a one sentence description of the patient and their CURRENT problem (i.e. Patient is a 7 month old female admitted for failure to thrive)

Another method for the plan, especially for complex patients is the systems based format:

CNS: Febrile/Afebrile, Pain control, neuro work up, etc.

PULM: Oxygen requirement, current therapies, etc.

CVS: Stable/Unstable, access, workups (EKG, echo, anatomical stuff like VSD, PDA, etc. etc.)

GI/FEN: Feeding (NGT, TPN, etc.), electrolyte abnormalities (K runs, abnormal bicarb, etc.)

ID:
Endo:
Hem/Onc:
Developmental:
Social:

Etc. etc. You get the idea. Of course if your patient only has one problem just go by problems, but systems is good for the trainwreck patients

 

[Tired]

I'm having a hard time standardizing my SOAP notes and H/P write ups...I just want to find the best way to write them and keep using the same style everytime. Does anyone have any sample write ups, links to sample write ups, advice, etc? I greatly appreciate your help!

I never really standardized my notes, since different services have different expectations. The descriptions people have proposed here are basically what I used on Medicine and FP (I also like the A/P #1, A/P #2, etc format). But if I wrote something like that on Surgery I'd be in a world of hurt. Peds was kind of between the two, but also had to incorporate some particular things (development, prenatal history). Psych of course has a completely different format. Then there's the whole matter of the ICU format . . .

In truth, my strategy has always been to look at the intern's note, copy the format and be a little more detailed. Generally that has served me well.

 

[Gem134]

I think for me, once I got the dang format down in my head, then I could adjust it on whatever service I was on. I know that might sound weird, but I had the hardest sort of "getting it" in my head mentally. Now when I do verbal presentations in clinic I am really surprised that my brief notes on paper actually translate into a reasonably fluid and decent oral soap presentation. How, and when did that transformation take place?

Mostly, it's endless practice and doing whatever the service requires - and reading other people's notes, plus reading numerous books. In other words, practice!

The UCSD site is also very awesome!!

 

[orthointern]

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