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Archive for January 8th, 2009

How to Write a Note

Posted by medliorator on January 8, 2009

The basic format for a note is the SOAP note

S – Subjective: any information you receive from the patient (history of present illness, past medical history, etc)
O – Objective: any data, whether in the form of a physical finding during your exam, or lab results
A – Assessment: diagnoses derived from the history and objective data
P – Plan: what you intend to do about the diagnoses from your assessment

The H&P should include the history of present illness, past medical history, past surgical history, allergies to meds, current meds, relevant family history… and social history… For HPI, a helpful mnemonic is OLD CHARTS:

O – Onset: when the problem began
L – Location: what area of the body is affected
D – Duration: how long has it been hurting, is the pain continuous or intermittent
CH – Character: words to describe the problem (dull, sharp, burning, stabbing, throbbing, itching, etc)
A – Aggravating / Alleviating Factors
R – Radiation
T – Temporal: is there any pattern to the pain, such as always after meals
S – Associated Symptoms

How To Write A History/Physical Or SOAP Note On The Wards [Scrub Notes]

Posted in Clinical Rotations, How-To | Comments Off on How to Write a Note