Basics for the Wards: Suggestions for improving your SOAP notes
When I was a first year we had basically no guidance on our notes, and as a result I was lazy with mine and developed bad habits. When I got to clinical rotations during third year my notes were horrible and it took a lot of feedback and effort to improve them.
In my experience helping med students improve their notes, as well as feedback on my own notes, here are some suggestions. This is mostly oriented towards an outpatient-type SOAP note, but also relevant to inpatient SOAP notes.
1. Note writing is different from anything else you’ve written before.
And it does not come intuitively, it is a skill that you work on. While a SOAP note or H&P may be a page or more, it is not an essay. You do not need to write “The patient says the cough causes pain in her left side,” when “Painful cough, left side” will do. You do not have to have perfect grammar and sentence structure. Why?
2. Condense condense condense.
Because nobody has time to read or write a novel. Be as brief as possible while still communicating the relevant info (what is the complaint? when did it start? inciting event? exacerbating/relieving factors? if their is paint what is the quality/radiation/level on a scale of 10, etc). This may mean you scribble notes in the patient encounter and then distill them in your SOAP note.
3. Organize the complaints.
Do not give me three separate sentences about the cough with an interjection in the middle that the patient stopped taking their headache medicine. Group your complaints together, with the chief complaint (AKA why they are there) at the top.
4. The subjective.
ALWAYS start your subjective with “Patient Q is a xyz year old M/F who presents with blah blah blah”. EVERY. NOTE. EVERY. TIME.
The subjective is where you write what people tell you. Everything in your subjective will be coming from the patient unless otherwise specified. YOU DO NOT HAVE TO WRITE ‘PATIENT SAYS’ or ‘HE/SHE STATES’ EVERY SENTENCE. We know the patient is saying those things, putting that in there makes your subjective wordy to read and time consuming to write. Remember, sentence structure doesn’t have to be perfect.
Every subjective should have a brief review of systems of things not included in the chief complaint. It does not take very much time and ensures that you are being thorough. Ones I always hit on are: headaches, fevers, fatigue, vision changes, nasal congestion, sore throat, cough, trouble breathing, chest pain, nausea, vomiting, abdominal pain, constipation, diarrhea, trouble peeing, muscle/joint pain, rashes, swelling.
Your do not need to put past medical/surgical/family history in your SOAP note unless something has changed or it is relevant to the visit (Ex: “Bobby is a previously healthy 5 year old boy with a history of asthma who presents today complaining of wheezing and shortness of breath” OR “MaryAnn is a 77 year old lady with a past history of multiple abdominal surgeries for diverticulitis who presents with a left sided abdominal bulge”). Otherwise, that info is in the H&P that was done when the patient was first admitted to the hospital or began coming to clinic. Your SOAP note is not a history and physical.
This is where data goes, things you see with your eyeballs or feel or hear. Most objectives are organized like this:
Labs (CMP, CBC, etc)
Physical exam (that you do!)
Imaging (ultrasound, chest x-ray, etc)
If you are hand-writing your note vitals go on one line like this:
BP HR T RR O2 (L/RA)
6. Objective: Physical exam
The biggest thing I have noticed is the first years either aren’t doing a physical exam or they write ‘normal’ or ‘no significant physical exam findings’. DO NOT EVER EVER EVER EVER DO THIS. Why? Well, for starters, your normal and my normal may be two very different things. ‘Normal’ does not tell me what you looked at, what it looked like/felt like, or help me see how you used your physical exam to arrive at your diagnosis. Finally, IT IS LAZY AND ARROGANT. As students we have not had the necessary clinical experience to say what normal is.
OK, time to regroup. There has been a lot of information. Summarize all your findings and what you think is going on, along with a differential. Example: Patient is an ### yo M/F with a chief complaint of XYZ, relevant objective findings such as vitals, labs, physical exam, imaging. Suspect patient has blah blah blah due to evidence, but differential includes yakkety yak and whatever.
I suggest grouping plan under each problem. So, if a patient is here with cough and sore throat but also has hypertension and needs a med refill, those would be two separate problems each with their own plan. Be sure to list dose of med and directions for taking it, as well as a return to clinic if (such as, return to clinic if no improvement in 3 weeks, consider antibiotics and imaging). This will help if someone sees the patient for followup after you. For clarity sake, I suggest formatting like this:
Problem 1 (chief complaint)
Problem 2 (second most important problem)
And so on.