Internship & Residency
Progress Notes
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Dr. Karl Newman
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Accurate notes are an important,
but sometimes unsung, part of the patient care process. In order to
properly convey critical data, interns and residents must make intelligent
choices about what information is essential, and what is superfluous.
This month, Q Fever!’s I&R correspondent, Dr.
Karl Newman, teaches you a systematic approach to: Progress
Notes.
Hiya, gang! It sure
feels good to be back. I missed ya’s! And ya caught me in a good
mood. That’s ‘cause today, we’re touching on a subject
that’s near and dear to my heart. You guessed it! Progress
notes. Without ‘em, your day might go a lot faster, but
stop writing ‘em for a week or two, and you’ll discover
what I did: Just because there ain’t been no progress,
doesn’t mean you don’t need a note.
So here’s some tasty tips from
Unkle Karl:
1. Know Your Notes.
Who dat? It’s
lil’ ol’ me, sayin’ you can’t write
a good progress note, till you know what kinds of progress
notes there are. The most basic type of note is the
SOAP note. That’s in comparison to other, more
acidy types of notes. Then, the next three notes just
happen to be “do-re-mi,” and if you know these, well, heck,
you can sing most ... aw, heck with it. Just a little light humor for
ya before the heavy stuff, ok?
Let’s explore SOAP notes a little
...
2. SOAP It Up, Baby.
You mean it, honey?
Sure I do. Each letter in “SOAP” stands for a different
word. Make sure you understand that little-known fact before proceeding,
otherwise the rest won’t make much sense!
The Subjective part
is where you write how you’re feeling that day. Confident? Angry?
Sad? Bemused? Discuss your opinions on current world events here too,
if you got ‘em. It doesn’t really matter, ‘cause no
one reads this part.
In the Objective
section, you’ll be documenting your physical examination. Vitals,
waist-to-hip ratio, hip-to-breast ratio, and hand-foot-mouth ratio all
go here. A small police-type sketch is useful, too. Don’t hesitate
to get a small policeman to help you with this.
Another thing to remember about the
Objective section is to use the right terminology. If a female patient
is in a frenzy and out-of-control, don’t use the word “hysterical.”
That’s because its root is hysterus, meaning “uterus”
in Latin, which might reveal you as sexist and misogynist. Use “histrionic”
or “melodramatic” instead.
Next up, the Assessment.
In many ways, this is the most important part of the note. It’s
pretty self-explanatory, if you ask me. Assess the situation.
Check to see that all major fire escape routes are clear. See if the
meds in the crash cart are all up to date. What are your chances of
making it out alive? Also, this is your chance to show how good you
are at differentials. And you thought you’d never get to use AP
Calc!
Lastly, we come to the Plan.
What are your plans after residency? Doing a fellowship? Going into
private practice? Getting sent back to China? A short essay on why you
became a doctor is appropriate. Keep it concise and to-the-point! Potential
employers have better things to do than to hear you ramble on and on
about yourself. The nerve of you!
3. Stay On The Up And Up!
Are you for real?
Yesirree Bob! Medicolegal aspects of note-writing are more
important than ever. Every thing you write, draw, dribble, or drool
out onto a chart can be used against you in a court of law. That includes
things that you started writing, but then tried to erase or cross out.
The simplest, and most effective, thing to do if you make a mistake
is to draw one line through it, then carve your initials next to it
using a small pocketknife. For larger mistakes, do what I do: carefully
cut out the offending area using a pair of scissors.
It’s also important to document
every conversation you have with the patient, whether they’re
at the bedside, at the driving range, or in your one-bedroom apartment.
I like to also document conversations I have about the patient with
colleagues, friends, neighbors, and people in line at the post office.
This kind of attention to detail will impress lawyers and juries alike,
if and when you’re hauled off to court!
Holy Mackerel!
Look like we’re out of time, ladies and gents! All I can say is,
I’ve really enjoyed our time together, and I hope you have, too.
Keep those pencils sharpened! And until next time,
“Just tell
‘em Dr. Karl sent ya!”
