"Nuts & Bolts 2" - A Guide to the Clinical Years Section 3: Insider's Guide to Inpatient Settings Table of Contents Charting & Note Writing It is important to learn organizational skills early on in your third year. These skills will help you with admission notes, SOAP notes, and patient cards. The more organized you are, the more refined your notes and presentations will be. This is important for your evaluations. To help you learn organizational skills, you should ask other third-year students, fourth-year students, interns, residents, attendings, etc., as well as consulting manuals. Index cards are key, but others use notebooks, PDAs, etc. It is critical to get your note writing done. Your notes can convey lots of information to other providers. It is also very frustrating for residents to stay late waiting for medical students to write notes. SOAP Notes This is a format for clinic and daily notes. SOAP notes are a legal necessity. More importantly, they allow other physicians to see how a patient's status has progressed and under what treatment. It is of great importance that you include in your assessment and plan both the treatment and the thought process behind each therapy. This will help those who cross-cover the patient at night and any consultant services. SOAP notes should be clear, complete and concise. The length will vary greatly among the services. Expect your longest notes to come from medicine and your shortest notes to be from OB/Gyn. See example below. These can be written anytime (even before rounds, depending on the service), but for new patients or ones with changing management you should wait until after the patient is discussed in rounds. E O/N (Events overnight): transferred OR, cardiac cath, etc. S ubjective: Chief complaint and other pertinent history. Events overnight. "Mr. Jones reports feeling much better today. Denies SOB, chest pain, fever and chills. New productive cough. Eating well. Otherwise without complaint." O bjective: Vital Signs usually include ranges (you should repeat the vital signs yourself if possible); PE: Includes the major systems (chest, CV, abdomen) plus involved areas; Labs; Cultures; X-rays A ssessment: 1) S/P possible MI, presently stable without chest pain. 2) New cough. P lan: 1) Check cardiac enzymes, taper nitropaste and arrange cardiac rehabilitation. 2) Follow temp, get new chest x-ray and obtain sputum. Hint: Ask your team if you can list assessment and plan together by problem (this is the way most house officers chart in clinic and on the wards): 1. Possible MI Presently stable without chest pain. Plan: Check enzymes, taper NTP, call rehab today. 2. New cough Pt. with productive cough, but no fevers or chills. Plan: will follow temp curve, get Cx-ray and obtain sputum if cough persists. Hint: You will need a separate record on each of your patients since you are not allowed to carry the patient's chart along with you. House staff use a variety of forms, the most common being 3 x 5 index cards (stamp the patient's name on the top of the card and fill in the History, PE, and Labs). Pre-formatted index cards are available at Millberry Union. They were developed by a UCSF graduate and many medical students find them quite convenient. (Always record daily vital signs, all labs, and PE changes. This will help when your attending asks you what your patient's BUN was two weeks ago.) Some students use plain old notebook sheets that they carry around on a clipboard. Clipboards are also a handy way to carry journal articles or conference notes so that they are always with you if you need them. Make sure you put your name and beeper number on your clipboard at the beginning of each rotation because clipboards are often lost. Many students prefer binder rings or binder clips (both available at the bookstore) to clipboards. Everyone changes his/her system a few times before figuring out what works best. What works for interns/residents may not be what works for third year students. Hint: Remember that your note does not equal your presentation. Remember not to say anything twice and to be more brief in what you say than what you write. It is not a bad thing if someone asks you questions after your presentation about the patient care and you know the answers.