Transcript
ZEN AND THE ART OF SOAP NOTE WRITING
A presentation on why SOAP notes matter, and how yours can be the best
By: Marcy Rosen
MD and avid SOAP note reader
In this presentation you should learn:
¨ Why we write notes on patients
¨ The 4 points of a SOAP Note
¨ Information most relevant to post-partum SOAP notes
WHY WRITE A SOAP NOTE?
SOAP NOTES ARE NOT FOR YOU!
S.O.A.P. Stands For…
• Subjective
• Objective
• Assessment
• Plan
Subjective/ Objective
Subjective: Just the facts
Subjective: Post-Partum Patients
Objective: Post Partum Patients
• Constitutional Status • Lung Sounds • Cardiac rate and rhythm • Breasts: Engorgement? • Abdominal Exam:
• Pain • Bowel Sounds • Fundal Size • Wound Status
• Visual Vaginal Exam: Lochia • Extremities: Swelling? Reflexes
Assessment
¨ Your assessment should explain in one sentence why the patient is there and how she is doing.
Assessment: Post Partum Patients
¨ Examples:
¨ 31 y/o G3P3 post-operative day 1 after primary c-section for fetal intolerance to labor
¨ 28 y/o G1 P1, post partum day 1 after NSVD
¨ 32 y/o G3 P2012, post partum day one after SVD, severe pre-eclampsia
¨ 19 y/o G1P1 day 3 s/p NSVD with chorioamnionitis, now resolved
Plan
¨ 1. Link the subjective and objective to the assessment
¨ 2. Address the next step in the patient’s clinical course
Important Points:
¨ Your note conveys the snapshot of a patient at a moment in time
¨ It is important to limit your note to pertinent information
¨ If you include something outside of normal limits in your subjective or objective, it needs to be addressed in the assessment and/or plan
Most importantly!!!!
¨ Your note is written for the next person reading it!
Most importantly!!!!
Write your note as if the next person
reading it has NO IDEA about the patient. Your
note should convey everything they need
to know.
Plus the added bonus:
Now: YOU are the expert!
You can do it!
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