Since I'm on call and have some extra time, that other post gave me the idea to put up a mock SOAP note for all those just starting off. It will help you get oriented as to how to write a note correctly. I added in some of the short hand that you'll need as well. For those who don't know SOAP stands for Subjective (how the patient feels), Objective (Vitals, Physical exam, & Labs), Assessment- (Short description of the patient; how they presented and their diagnosis), Plan-(what will be done to treat the patient)
As far as presenting your patient, different attendings want you to present differently. Some want you to go over your whole note in gross detail, some just want you to get to the point. Here's what I do everytime I present to a new attending:
Now when you present the O section do as follows:
"All of his vitals were stable, do you want me to go over them individually?" (now if they want you to go over all the vitals, that means they probably are the type that want detail so just give them EVERYTHING. It's long and exhausting, but some attendings like that......for some strange reason lol).
Option #2- Just begin saying everything in detail and then the attending will cut you off if they don't want to hear it all. (this is probably a safer way of doing it, but some of them get really annoyed by it lol)
In general, just stick to the format, only say what's on your note, DON'T MAKE UP STUFF AND DON'T LIE....you'll get caught and/or you'll be really embarrassed. If you miss something, most of the time your residents will jump in and save you before u end up looking dumb for not knowing xyz.....if you have good residents that is . Just remember to do the same for them and you'll be fine.
Ok, with that said, here's how you present your patient and write your note:
(Before you present the Subjective, first just state the Assessment and then go into subjective so it will sound like this: "44 yr old white male with past medical history of HTN, Diabetes, presents with nausea and vomiting for 3 days secondary to medication overdose. Patient states that his nausea has improved this morning with no vomitting. No chest pain, No shortness of breath, no fevers/chills, tolerates diet")
S- Patient states that his nausea has improved this morning with no vomitting. No CP (chest pain), No SOB (shortness of breath) no fevers/chills, tolerates diet (this means he can eat without vomiting)
(for vitals, remember to give ranges....the highest and lowest values for that day and the day before)
O- Tc (current temperature)-36, Tmax- 36.3, R- 18-20, P-70-84, BP- 100-120/75-77, O2 sat- 99% on room air, I/O- 2000/2600 (ins and outs....fluid intake/fluids out)
(now if your patient has a normal physical exam with no pertinant abnormalities, you'll write it up like this, if not, just write what you see/hear...if you don't check something DON'T WRITE IT, and I'll warn you ahead of time, don't lie!!)
General- NAD (No apparent distress), AAOx3(awake alert & oriented x3)
HEENT- NC/AT (normocephalic/atraumatic...basically means the head doesn't have any signs of trauma), PEERL (pupils equal & reactive to light,), EOMI (extraocular muscles intact), neck supple, no lymphadenopathy, no JVD
Cardio- RRR (regular rate & rhythm), no MRG (murmurs, rubs, gallops)
Resp- CTA B/l (clear to auscultation bilaterally), no wheezes, no crackles, no rhonchi
Abd- soft, NT/ND(non-tender/non-distended), no hepatosplenomegaly, no palpable masses
Extremities (don't forget this one especially if they have cardiac problems)- no edema, 2+ pulses throughout
A- 44 yr old white male with past medical history of HTN, Diabetes, presents with nausea and vomiting for 3 days secondary to medication overdose.
(Now, there are 2 ways to do the plan, either systems based or problem based I like systems so I'll write it like that. Also, for this section, if you can, go over it with your resident before hand and/or copy the plan from the day before and just add in any changes that have occured (new x-rays, mri's, changes in labs, improvement in the patient's condition etc.)
P- 1. GI- Nausea/Vomitting- Resolved, continue Phenergan
- Abdominal X-ray (4/9/07)- Negative (this means no abnormalities)
2. Cardio- HTN- Controlled, Continue current medications (if you want brownie points list them individually)
3. Endocrine- DM- Finger sticks increased from 200 to 400. Increase Lantus to 40, add SSI (I'm totally making this up lol)
4. FEN (This is basically what type of diet they are on and what IV fluids they are recieving)- Cardiac diet, ADA(american diabetes association) diet, 1/2 normal saline at 122cc/hr
5. Supportive (this is the DVT and Heparin prophylaxis...ALL patients will have either one or both)- DVT PPx- Heparin 5000U
- GI PPx- Prevacid
6. Code Status- Full code
Extra: Also some hospitals will want you to list the patient's medications in the upper left margin.