question about writing a soap/progress note

[KMinton]

Having trouble making SOAP notes concise for busy OB/GYN clinic. Any suggestion about sites that have good examples of concise/ real- life SOAP notes, not the longones they teach us to do in class.

---

Members don't see this ad.

 

[cbrons]

Not really, I am horribly slow doing this as well.

What I did on for family medicine was to get a copy of a soap note that the attending wrote himself and copied down word for word (minus any patient information) so I could have it written exactly how they wanted. Of course this is because he graded my notes.

 

[Ismet]

One thing you'll learn extremely quickly in 3rd year is that every attending has different preferences for notes and presentations. Do what @cbrons said, check out some notes written by whatever attending or resident you're working under and use that as a template for your note, it will give you much better results than using a random online template. I've had attendings tell me my notes were really great/organized/well thought out, then the next week an attending would pick apart my note and all the things wrong with it because that wasn't the way they liked to see notes. It sucks but you have to be flexible and just make sure that you only have to be told once.

 

[Kaustikos]

Copy and paste EMR notes. Whatever attending you have... use their notes. Or don't write notes since it's not billable and no one reads 'em.

 

[Ismet]

Copy and paste EMR notes. Whatever attending you have... use their notes. Or don't write notes since it's not billable and no one reads 'em.

Or you can write a good enough note that the resident or attending copies from you.

 

[Kaustikos]

Or you can write a good enough note that the resident or attending copies from you.

I never said one couldn't do that. But as a third year medical student... it's often better to follow by example when needed. When you're the only person other than the intern/resident that day and notes need to be written, it's not the time to hand craft some progress note but instead use others notes to get the job done.
Again; I agree that making your own good note is the best. But that comes with experience. And, also, time. Residents have been more appreciative of doing what I said because it's working as a team. Which is my point.

 

[Ismet]

I never said one couldn't do that. But as a third year medical student... it's often better to follow by example when needed. When you're the only person other than the intern/resident that day and notes need to be written, it's not the time to hand craft some progress note but instead use others notes to get the job done.
Again; I agree that making your own good note is the best. But that comes with experience. And, also, time. Residents have been more appreciative of doing what I said because it's working as a team. Which is my point.

We're told exactly the opposite actually, we have to write our notes ourselves. Of course we can draw info from past notes if necessary, but copy/pasting has gotten people in trouble. I follow by example by using the general template/format that the team is using, but other than that I write everything. Copy/pasting just perpetuates the same mistakes if there are any, and I caught several of them on my inpatient rotation. By the end of 3rd year I feel fairly efficient with H&P's and notes.

 

[Armadillos]

My advice is for every 4 words you think are worth writing, get rid of three them. Check out the billing requirements sometime, you can bill a pretty high level visit with a couple line note if your efficient.

 

[cabinbuilder]

Having trouble making SOAP notes concise for busy OB/GYN clinic. Any suggestion about sites that have good examples of concise/ real- life SOAP notes, not the longones they teach us to do in class.

Do have a Maxwell" pocket reference? It has perfect SOAP notes for H&P, on service note, progress note, discharge note, pre-op, op n0ted, post op, procedure note, delivery note, post partum note, apgar scoring exam. Just copy what it says and tweak for your patient. You will be golden every time.

 

[Kaustikos]

We're told exactly the opposite actually, we have to write our notes ourselves. Of course we can draw info from past notes if necessary, but copy/pasting has gotten people in trouble. I follow by example by using the general template/format that the team is using, but other than that I write everything. Copy/pasting just perpetuates the same mistakes if there are any, and I caught several of them on my inpatient rotation. By the end of 3rd year I feel fairly efficient with H&P's and notes.

I'm not talking about literally copying word for word. That was me exaggerating what is essentially using a reference that's acceptable on that service. I'm talking about using their notes as a template for how you write yours. If you're following on rounds and noting the changes, then you just put those changes in the notes in the way they like.

Yes, they say don't copy/paste. Yes, people do get in trouble for mistakes. But then they say our notes don't matter and not to bother writing them. So....