when writing the progress note (SOAP), how far do you go back for meds?

[hippocampus]

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for example, let's say they are taking a drug "1 tab PO daily."
you have to write a progress note in the morning.
how far do you go back?
do you look at the DATE or TIME the drug was given?
do you include IV fluids?

 

[smq123]

for example, let's say they are taking a drug "1 tab PO daily."
you have to write a progress note in the morning.
how far do you go back?
do you look at the DATE or TIME the drug was given?
do you include IV fluids?

I'm not clear on what you're asking.

When you are documenting the routine meds on the progress note, just write "1 tab PO daily." No need to document the specific time that the drug was given. And if they take it daily, then no need to document the date either - theoretically, they take it every day.

Yes, when documenting the meds on the progress note, include IVF.

 

[EternalMD]

It would depend on what medication the patient is on. You would normally document the usual: Drug, amount, route, frequency (normally you don't write holding parameters on daily progress notes)

Certain drugs like anti-biotics its a good idea to write down what day they are on of what duration. i.e. --> Vancomycin 1g IV Day 5/14.
If the patient received a PRN drug like Haldol, you can document like normal and then next it write (3 doses: 3am, 6am, 7am). Often times this is important because it gives you an idea of whats going on with the patient i.e. the patient received 3 doses of Haldol over a short period of time and the patient was still agitated vs 1 dose given prior to bed and no problems after

 

[surrender903]

i ve only been on one service where i was required to write daily meds. i would just write what the pt is on at the time im writing the note.

 

[Blade28]

Are you asking if you should include D/C'ed meds on the progress note? Or prn ones? One-time doses? 😕

 

[Law2Doc]

i would just write what the pt is on at the time im writing the note.

Yeah, the SOAP or progress note should be what the patient is currently getting. I would also include PRN and IV infusions (but with those headings).
For presentation purposes, where you are expected to know everything about your patient, it probably pays to know what their home meds were, what PRN meds actually got administered, and what has previously been tried during the hospital course (esp regarding antibiotics. No point putting a patient back on something that didn't work in the 14 day course they just finished last week). But all this should be in your cheat sheet/note card, not in the progress note.

 

[pincheeric]

IV infusions should go with medications. IVF should go with Ins and Outs, not meds.

 

[Law2Doc]

IV infusions should go with medications. IVF should go with Ins and Outs, not meds.

I guess this is dependent on your school and/or attending. What you describe is not the way some places like it. Do what is customary for where you're at.