Introduction to Clinical Medicine-SOAP Notes – Flashcards
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-Find the correct diagnosis -Tell how you proved it -Rule our other potential problems -Display your medical knowledge -To really shine you want to add some pertinent facts and statistic then end with a bit of amusing trivia
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Your job as a student when writing notes
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-S: subjective -O: objective -A: assessment -P: plan
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SOAP acronym
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-Chronology -Onset -Duration -Intensity -Exacerbation -Remitting -Symptoms associated
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CODIERS
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-Have you had this before -How many times -What did you do for it -Did you see a physician -What did they do -Did that work well
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Chronology
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-When did this start -What were you doing
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Onset
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-How long does it last -Has it changed
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Duration
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-How bad is it -Typically refers to a scale (1-10) that is pertinent for changes in the pain
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Intensity
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-What makes it worse
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Exacerbation
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-What makes it better -If a drug made it better: what drug; how much; how often
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Remission
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-Things they may or may not have
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Symptoms associated
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-Surgical history -Medical history -Allergies -Social history -Hospitalizations -Family history -Medications
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SMASH FM
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-Food (diet) -Exercise -Drugs -Tobacco -Alcohol -Caffeine -Occupation -Sexual history
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Social history-FED TACOS
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-Medications -OMM -Tests -Holistic/humanistic -Referrals -Return
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Plan-MOTHRR
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-Starts with date and time in the left upper corner -Every note must contain the patient's name somewhere on the sheet -Medical record number
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The SOAP note
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-What the patient tells you -You are not responsible for making certain it is absolutely correct -You are required to record it as accurately as possible
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Subjective data
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-Chief complaint (simple and in the patient's own words) -History of the present illness (CODIERS in a paragraph format) -SMASH FM in a bulleted format
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Subjective information includes...
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-Grouped as positives and negatives -Include the things that point to what you believe is the correct diagnosis and things that point away from the diagnosis you are trying to rule out
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Symptoms associated should be....
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-Vital signs, physical exam results, test results -Facts that you have determined -You are responsible for the veracity -Always record this accurately -Never record anything you did not actually check -Outline format to make it easy to read
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Objective information
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-Bulleted with headings: vitals; general assessment (mood and appearance) -Then work head to toe -Test results
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Physical examination
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-Differential diagnosis
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Assessment consists of....
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-Primary diagnosis first: you must commit to some kind of primary diagnosis even if you are uncertain; cannot be stated with rule out or doubt; must need three diagnoses here -Secondary diagnosis next: do not relate to the chief complaint; any other diagnoses that you intend to address
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Differential diagnosis
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-Bulleted or numbered (MOTHRR) -Keep it short and sweet -It is not necessary to have a plan for every diagnosis in the differential, just for the primary one
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Plan
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-End with legible name and signature: if your signature is legible that is it; if your signature is not easily legible print your name -Sign directly below your last line of text: no one can write in your notes or change your notes; this is also a legal document
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SOAP note endings
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-Start with CODIERS -Add a complete review of systems -Head to toe physical exam (not just based on the chief complaint) -Assessment and plan may be much more complex in a patient with multiple conditions
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Full history and physical exam
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-Show that you asked everything and checked everything -Ask the patient about symptoms in the past and present -Ask observers (family members) about symptoms -Examine the patient for the symptom -Lab test if possible -Bring them back and recheck in a week or so
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Do not try to minimize the information in your SOAP note
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-Do you use recreational drugs -Are you sexually active
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The tough questions
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-Written the day of surgery -Gives a brief recount of what they are going to the operating room for -Shows that you have thought about this situation the day of the operation -Ensures that nothing has changed since you scheduled the procedure
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Brief pre-op note
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-Put on the chart after the procedure -Documents everything that might be needed until the operation note is on the chart -This information can make it easier for nurses and other physicians to understand what happened in the operating room -It could save the patient's life
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Brief operative note
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-Longer version of brief operative note -Contains detailed description of procedure -Usually dictated by surgeon -Will not make it to the chart for several days
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Operative note
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-May be simple or complex -Extremely important in a complicated patient or long hospital stay -Should contain everything you would want to know if you were the next person to take care of this patient
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Discharge summary
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-Date of admission -Date of discharge -Admitting diagnosis -Final diagnoses -Consultations -Operations/procedures -Brief history and physical -Pertinent labs -Hospital course -Disposition -Discharge medications -Discharge instructions
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Discharge summary contents
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-Property of the hospital -They are responsible for maintaining the chart, storing it, and providing copies -The hospital cannot bill for the patient's care until the chart is complete -Sign your charts
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Inpatient charts
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-Demographics -History and physical -Progress notes: admission note, progress notes, procedure notes, OMT notes, pre-op notes, brief operative notes, post-op notes -Consultations -Operative notes -Laboratory -Imaging -EKG's -Nursing documentation
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Inpatient chart contents
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-Arranged in sections -Demographics: age, sex, race -Problem list: active, inactive, removed, sate of onset, date of resolution -Medication list: active, past, last refill dates -SOAP notes -Laboratory -Imaging -Consultations -Correspondence
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Outpatient chart contents
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-Property of the medical office -Arranged for you convenience -Still a legal document -Must be kept on record for a specific amount of time -You must provide copies when necessary
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Outpatient chart
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-Contains everything pertinent to the situation -Does not contain excess or meaningless information -Perfectly legible -Completed in a timely fashion
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The ideal note
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-Complete blood count
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CBC
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-Clean shaven or have a definite well-kept beard -Tighten your tie
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Rotation appearance for men
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-Heels are not practical -Need to maintain clothing that allows for proper movements -TV fashion is not appropriate
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Rotation appearance for women
