SOAP Notes

[vegas]

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After writing your SOAP notes in the chart during prerounds, do you guys make a copy of the notes or rewrite them on your personal notepad inorder to present them during rounds? I am looking for an efficient method w/o having to memorize! Thanks in advance.

 

[NateatUC]

After writing your SOAP notes in the chart during prerounds, do you guys make a copy of the notes or rewrite them on your personal notepad inorder to present them during rounds? I am looking for an efficient method w/o having to memorize! Thanks in advance.

Do you have to have your note in the chart before rounds? Personally, I usually don't even have the Plan totally written until after we've discussed the patient on rounds. I usually start my note on a new sheet, then keep it in my pocket, present from it during rounds, then put it in the chart after I write down the Plan we've discussed. Of course, if you have to actually have the note in the chart, this won't really work, so you'll have to copy it, or at least have the pertinent info handy.

Of course, I also keep a note card on each of my patients, so that I know something about them after I put my notes in the chart.

 

[DrMom]

We have to have the notes done & in the chart before rounds.

I would note labs or any other significant info for each pt on my daily pt list or an index card. Never really had a problem remembering significant findings from the physical exams, but those could be jotted down, too.

By the end of 4 months in the hospital, I was able to keep things straight in my head better & didn't write down much at all.

 

[vegas]

Do you have to have your note in the chart before rounds? Personally, I usually don't even have the Plan totally written until after we've discussed the patient on rounds. I usually start my note on a new sheet, then keep it in my pocket, present from it during rounds, then put it in the chart after I write down the Plan we've discussed. Of course, if you have to actually have the note in the chart, this won't really work, so you'll have to copy it, or at least have the pertinent info handy.

Of course, I also keep a note card on each of my patients, so that I know something about them after I put my notes in the chart.

I've tried all kinds of methods! One of them being as you mentioned writing the note beneath the previous note and holding onto the sheet until we rounded on the patient. But this presents a problem for other services covering the patient where all the notes are needed if everyone is rounding at the same time of day. I even started a new sheet for my own note until a nurse yelled at a resident for doing the same because it was a waste of paper in her opinion....so that idea went south. I've also tried the note card thing...just doesn't work for me.

 

[DOtobe]

I agree with DrMom - once you get used to writing notes and get used to the patients you are seeing, you don't need to write down much of anything. I used to try to write everything down, but that took too much time. Now I just jot down labs (although after a while you will even remember abnormal lab values) and remember if anything significant happened with the patient overnight.

On most of my rotations we have had to have the notes done before rounds started.

 

[AF_PedsBoy]

During my sub-i's we needed to have all the patients SEEN but the notes just had to be written before the attending got there.

A good morning routine is buzz in, grab the patient census (30 seconds), check labs for alll your patients (~five minutes). Then for each patient eyeball all the notes after yours to figure what's going on (two minutes), check vitals and nurse's notes for events (two minutes), and then stop by the Cardex to figure last dose of pain med/number of doses given (one minute). Then stop in, quick hello, run through symptoms (two minutes), and a quick two minute physical and on to the next patient. Since you average about ten to twelve minutes per patient you can finish your whole census in an hour and a half, run any plans past your chief, and be ready for attending rounds. A quick presentation and plan later, you grab some coffee, and then jot the note in. If your patients are all clustered somewhat together you can actually get all your notes written in about an hour ~5-8 minutes a note.

I'm still advocating the quarter-folded sheet of paper for each patient since you can have the history and admitting meds list on the front and then each day you go to the next quarter, so if the attending asks you for hospital course (when did that J-tube go in? or, what was their Hgb like on admission?) you can just flip over to the front, or turn to the right day. The only thing I write is: S) Current sx I'm asking about/new sx; nursing events/consult info/new meds; O) Vitals, PERTINENT physical findings (none of that RRR, or lungs CTA B crap, since I can fill it in myself when I'm presenting), and labs; A/P) Current plan (e.g. OR tomorrow, PFT's on Friday) and a nice blank space for what the attending wants done that day.