1. Accurate date and time
This is of medico-legal importance. Errors in dates occasionally occur on call as the clock strikes twelve midnight and the date changes. The wrong year is also often written at the start of January. It often helps to countercheck quickly with the dates of the other recent entries. Also, do not be that intern who rounds at 10am, but writes 8am. Not only is it unfair when it makes others look bad in comparison to yourself, but also actually dishonest.
2. Identify yourselves (team, and names of seniors)
This is important so that others can contact you for clarification if needed. Ideally, the documentation for plans should be sufficiently self-explanatory to render further clarification unnecessary. Identifying the team involved in the care makes follow up and inter-team communication easier.
3. The SOAP note
The purpose of a SOAP note is so that there is a standard format for organising patient information. If everyone in the team used a different format, it will get confusing when it comes to reviewing a patient’s chart. SOAP stands for subjective, objective, assessment and plan.
When documenting using the SOAP mnemonic, always remember to include the most important information, but in the typical/expected sequence. Whatever is a “problem” or a potential “problem” will need to be mentioned. Important plans made by the team needs to be stated in the “plans”. Interns should note that the SOAP notes are not only used for charting purposes but you will also use it as a guide when doing an oral presentation on the patient.
The components of a SOAP note:
Subjective and objectiveFirstly, interns should begin with this section. “Subjective” refers to a patient’s subjective opinion of his/her progress, or any symptoms. If this is a typical ward round, document how the patient feels he/she is. While “objective” refers to measureable observable markers such as vital signs, input and output, especially for general surgery and examination findings. If relevant, laboratory findings may be included here as well.
AssessmentThe next section is the assessment where the patient’s diagnosis should be noted. This should indicate a succinct review of the situation.
The planFinally, this is where important changes to the current management need to be communicated. It may involve ordering additional tests to confirm or rule out a diagnosis. If the plan is not written clearly, the needed treatment might not be carried out.
Here’s an example of a chart:
Interns will find that using a set format will make things easier for them. While following this sequence is not the most important thing, take heart that you are on the right path as long as the most important and relevant information is included. MIMS
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