Currently I’m in Family Medicine clinical clerkship rotation and it’s kind of hectic when you have over 60 patients to see and you have write soap notes for all of them. During rounds, the attending doctor asks us what did we find that was abnormal since the last progress note and we report what we find. If there is no abnormality then we just report that and also we report if there is a change in medication.
Honestly, it is a burden to go through those patients’ charts and update the progress report that I do. It takes time to go through those charts and trying to read the notes written by people who needs to go back to grade school for writing lessons. Medical students who were assigned those patients before us wrote the previous progress notes in the charts so each progress note is written by a different individual. However, few progress notes are written by attending doctors and it looks like as if they are writing another language.
When writing a soap note we write something like the following:
56 y/o AAF with PMH of HTN, DM, hyperlipidemia, and depression. On questioning she has no complaints.
The following is in short hand for 56-year-old African America female with past medical history of hypertension, diabetes mellitus, hyperlipidemia, and depression. It took me a while get the small short hands memorized but eventually I got through so when I see it I get it. Also there is a pattern of what drugs are ordered for the patient. For example for Extra Pyramidal Symptoms (EPS) the doctors always prescribe benztropine for Parkinson’s like symptoms which can be caused by the side effects of an antipsychotic drug such as haloperidol.
Through practice and monitoring the patients you speed up and it helps so much in your clinical skills in soap notes writing.