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Initials patient progress report

hey guys doctor decide here from osmosis and I wanted to talk to you guys this week about how to write a really good progress note or clinical note and I brought with me a little prop so this is just to remind you uh what we're talking about today and if you've written a note before you know why I'm holding this up let's see if I can there it is s OAP subjective objective assessment and plan write soap or soap notes are what we call them sometimes and it's just a shorthand from one remember kind of what what we should include in the note the subjective is what a patient tells you objective is kind of what you determined by yourself through physical exam or labs or imaging assessment is kind of thought process what do you think is going on and explaining that fully in a plan is just that it's like what are you gonna do next so this is a soap note format it's pretty universal and so this is what we want to talk about today what are my top three tips for writing a good note and this is kind of over the over the many years I've kind of started really thinking about it and come up with it let me dive into what I like to do so my top three tips top tip number one write a story keep in mind when a patient comes to you and they have a problem whatever problem they might have they they'll say oh you know my hip hurt and then I was walking and I hurt more and now I feel like you know maybe it's getting really really bad added and you asked him Oh what-what do you think caused that oh you know I think he may have been because I went to the gym you know and I was exercising so you're kind of putting together supporting sometimes you know it's hard as a patient to kind of put the story in order a chronicle chronological order they're kind of just telling you bit to this story it's your job in the history and physical which is also kind of the subjective and objective part to lay out the story and say okay look we understand that you had kind of hip pain but let's start with kind of going to the gym and then the hip pain started maybe three days later and then on on physical exam or the assessment part I noticed that it's hard for you to move your hip in a certain direction so maybe that kind of gives you a clue as to what's going on so that's telling a good story you know for example say story if you're not telling a good story would be like Oh a person had hip pain and then a month ago they had a runny nose and it lasted three days and and then they recently traveled to New Zealand and they came back and they they eat a lot of kind of fatty foods it's kind of all over the place right that's not a good story I think if you're listening to a story like well what's going on where's the where's the story arc what's what's even happening if you're watching a TV show like that you probably click away right so tell a good story write a good story make it make sense logically because what it does is it kind of feeds into the next parts of the of the history and once a okay so tell me more about the Jim what are you exercising where you were exercising the orange lights to write out when you're doing your history in fiscal and you're writing down your soap note in your subjective and objective you want it to flow very natural it makes sense so it kind of builds up to a crescendo which is your assessment so tip number two remember that when you're doing the assessment a diagnosis is a label so it's very very important once you write down a diagnosis in your chart you know you write in your assessment you know I think this patient has you know let's say a depression or chronic fatigue that label is gonna stick with that person they're gonna go around that patient chart it's gonna follow them and so remember that that's not an easy label to kind of shake off I'll give you a quick story I had a patient who is vitamin b12 deficient and in the chart it said things like you know patients depressed patients kind of feeling headaches and because it said those things every time the patient said oh I feel really fatigued retired people just said oh well you know in the chart it says diagnosis depression so that's probably what it is and they didn't really think or given any kind of value and so when you write your assessment to write your diagnosis you know every other doctor is gonna see that and they're gonna kind of think in the same way so you're really cheating that patient out of giving them a fair shot getting the real diagnosis so when you write your assessment think about all sorts of things like what's the worst case scenario what is the full differential of what could be going on and if you're not sure about something you can add that in your assess and say look this seems possibly to be depression but other things that we should really consider would be you know causes like hypothyroidism or vitamin b12 deficiency so just writing that out and even if you don't have the answer just saying like there could be other causes or something about this doesn't make sense it's really really important so just make sure you put your full assessment in there so you don't cheat someone out of getting the right diagnosis maybe down the road all right next the third tip and make a specific plan not just like plan to lose weight but maybe reduce soda from three times a week to one time a week or start drinking a healthy smoothie for breakfast and maybe even look up a recipe of the patient so when you're doing the plan I want you to be very specific so say things like hey this patient has agreed to kind of going down on their cigarettes from 20 cigarettes to 10 cigarettes a week you know very very specific and that's like why when I started writing soap notes I used to think oh you know what a soap note is a way to communicate with other doctors and nurses and pharmacists my thoughts that's what I thought and that's true but then about a year later I started getting meetings with people in the hospital that said hey we want you to write your soap note so that it actually makes sense for insurance companies for the EMR and so we wanted to check all these boxes and I thought oh okay so I guess the soap note is a legal document business document so that we have to communicate with insurance companies what we're doing so we get paid so that okay that's what that's what a soap note is for and then as I kind of went on I realized actually it's not just that it is that but it's also something more it's also a contract between you and your patient it's it's a trust you're saying to them and this is what I do know with my soap notes I read my soap note back to my patient you know at the end I'll say kind of like just quickly highlighting the things that I think are important and then when I start a new visit like a faecium in a few months I read it again and say hey last time what we talked about was this this and this is that you're understanding and they say yeah that that's about right and they can kind of fill in the gaps too so I really want you to think about your progress notes as a contract between you and your patient and the goal of a good soap note is to a get the information right you know again writing a good story tip number one it's it's number two make sure that the the assessment is truly thought through because the assessment or diagnosis is a label so make sure you think about that and number three make sure that when you're writing a plan it's very specific so again number one write a story number two remember that your diagnosis is a label and number three make sure that you write a very specific plan I'll see you again later bye bye start your free trial today at us Moses org [Music] you [Music]