Getting Used to SOAP Notes



Currently I’m in Family Medicine clinical clerkship rotation and it’s kind of hectic when you have over 60 patients to see and you have write soap notes for all of them. During rounds, the attending doctor asks us what did we find that was abnormal since the last progress note and we report what we find. If there is no abnormality then we just report that and also we report if there is a change in medication.

Honestly, it is a burden to go through those patients’ charts and update the progress report that I do. It takes time to go through those charts and trying to read the notes written by people who needs to go back to grade school for writing lessons. Medical students who were assigned those patients before us wrote the previous progress notes in the charts so each progress note is written by a different individual. However, few progress notes are written by attending doctors and it looks like as if they are writing another language.

When writing a soap note we write something like the following:

56 y/o AAF with PMH of HTN, DM, hyperlipidemia, and depression. On questioning she has no complaints.

The following is in short hand for 56-year-old African America female with past medical history of hypertension, diabetes mellitus, hyperlipidemia, and depression. It took me a while get the small short hands memorized but eventually I got through so when I see it I get it. Also there is a pattern of what drugs are ordered for the patient. For example for Extra Pyramidal Symptoms (EPS) the doctors always prescribe benztropine for Parkinson’s like symptoms which can be caused by the side effects of an antipsychotic drug such as haloperidol.

Through practice and monitoring the patients you speed up and it helps so much in your clinical skills in soap notes writing.


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5 comments:

Anonymous said...

If you are going to insult others for their writing, at least correctly state the sentence in which you are insulting them:

"notes written by people who needs to go back to grade school for writing lessons. Medical students who were assigned those patients before us wrote the previous progress notes in the charts so each progress note is written by a different individual"

If you think nothing is wrong with either of those 2 sentences, you have no business insulting others.

Medical Student said...

Anonymous: you have no business telling me what to do...I have said something as a way to express my frustration that holds me back from doing my job in an efficient manner and you're complaining about that?

Ola Blessed said...

Anonymous... Chill. It's Med School's blog. Not yours. He/She has the liberty to write as they please. It's a blog and not a note to the attending. Get over it.

Med School... I've been following ya before I even started at SJSM! So that's about over a year now. Your posts are always helpful and it's extremely interesting to you watch your progress! You rock ;)

Anonymous said...

Hey i'm a prospective student at St. James and was wondering if something i heard from a close friend is true. She told me that St. James had a match rate of close to 85% this year. Are kids really that smart there?

Medical Student said...

Ola Blessed; Thank you for following this blog and thank you for the encouragements. I hope it will help you further as you progress in your medical school

Anonymous: So far everyone I know of from what I know got pre-matched and matched from St. James so I think you heard it right. You don't have to be super smart to get a residency, you just have to work hard and know what you want.

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