Just a few reminders for your SOAP notes. I will leave you individual comments when I grade them but these are some general tips to make top marks.
1. Your HPI MUST contain ALL elements of OLDCARTS
· O (onset) L (location) D (duration) C (characteristics) A (associated factors) R (relieving factors/radiation) T (treatment) S (severity)
· Make sure your HPI is specific to their chief complaint
· Make sure your HPI has all components of OLDCARTS written in paragraph form
2. Past medical history should be in a list format
· Example:
i. Hypertension
ii. Chronic kidney disease
iii. Asthma
3. Family history should list only pertinent medical problems (cancer, heart disease, etc.)
· Spousal history should not be listed here, only blood relatives to the patient
· Example:
i. Father: Hypertension, CAD (deceased at age 81)
4. Review of Systems
· Must contain at least 3 elements per system
· Is only subjective (what the patient says)
i. Ex: Pain
· No physical exam findings should be documented here
5. Physical exam
· If you don’t examine it DON’T document you did. Write ‘deferred’ or ‘not examined’
· EVERYONE review medical terminology
· Pain is not a physical exam finding (remember, this is subjective). Tenderness is a physical exam finding
· EVERYONE review components of a neurological exam, including cranial nerves
· EVERYONE review what a mental status exam is
i. There is a document in your course with components of this
ii. It doesn’t need to be extensive. A brief description of the patient will suffice
1. This 35-year-old male was casually dressed in jeans, t-shirt, and sneakers. He was pacing throughout interview, although was cooperative. Denies suicidal ideations, homicidal ideations, or hallucinations today.
2. Patient is calm, cooperative, without anxiety, depressive symptoms. Denies suicidal ideations, homicidal ideations, or hallucinations today.
6. Diagnostics
· Only write what was ordered (labs, imaging, etc.) with results
· If you think your preceptor missed an important diagnostic order write it in
7. Differential Diagnoses
· List at least 3 differentials with evidence showing me how you ruled it in or out
· Listing symptoms will not be enough
8. Treatment
· Write your medications in prescription form
i. Metformin 500mg po bid (0 refills)
ii. Amoxicillin 500mg po daily x14 days (0 refills)
· Do not write medications that were not ordered. I don’t want a list of traditional treatment for the diagnosis, I only want to see what you ordered and think is medically necessary.
9. Make sure your references are cited correctly. You must have at least 3 per SOAP.
complete in the soap note 9
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