Soap Note Patient Name: Fill & Download for Free

I don’t normally write “non-serious” medical answers, but some of these are - so if I don’t get many upvotes, I’ll probably decide to abandon humorous responses. I don’t necessarily consider these “Neat”, but nonetheless, they are characteristic of (someone’s) pathology. For what it’s worth -A “Checkup from the neck up” - psychiatric consultChronic Recurrent Abdominal Pain - a term used by frustrated doctors who can’t find a reason for the patient’s abdominal symptoms (I’ve learned that our inability to find a cause for someone’s symptoms doesn’t make them any less real)Dump - A patient with multiple medical problems and no insurance transferred to the charity hospitalDumpling - pediatric version of aboveEuboxia - all lab values are within the normal range (fall inside the box)A follower of Bacchus - Used by residents when presenting a patient (at the bedside) when they are uncomfortable saying that the patient is an alcoholic. (Comment: Even doctors may help patients maintain their denial)SOAP note - a progress note containing - Subjective (patient’s stated symptoms) - Objective (physical signs, lab, x-rays, etc.) - Assessment - what is going on with the patient - their diagnosis or other significant characteristics of their condition - Plan - What to do next in evaluation or treatment.Trichotillomania (the urge to pull out one’s hair due to a genetic disease called Trichomalacia) produces bald spots due to that compulsive urge. Trichomalacia is also the resulting condition (absence of hair -bald spot)Q - So, what’s the difference between a hematologist and a urologist?A - A hematologist pricks your finger…..Q - So what’s the difference between an orthopedic surgeon and a carpenterA - A carpenter usually knows the name of more than one antibiotic

A2A.Yes. It’s worth remembering that in the U.S., the median age of incoming medical students is around 23 or 24 years old. Many come fresh out of college (22 years old). I can’t say I knew anyone in my class who was so grossly deficient that I thought “they shouldn’t be a doctor.” Medical school is a growth process. Sure if some of them were the same person they were when they came in during first year, I’d be concerned of them being a doctor. But everyone, as far as I was aware, had risen to the role over the course of four years.I do recall one particular family practice intern that I encountered during my third year who had gross deficiencies in reading EKG — she was unable to discern STEMI, V-tach, V-fib, and other basic rhythms. She was also unable to put together a coherent SOAP note and presentation for attendings during rounds. Now, again, I understand that it’s all a learning process, so I never thought she shouldn’t be a doctor. But the deficiencies in this intern resident stood out to me, even as a third-year medical student. I did wonder, “How did this person pass boards and become a doctor?”There are other residents I have come across in the course of my career who have, frankly, horrendous bedside manners. These are usually residents who come to the U.S. from foreign countries, namely the Middle East and India, where bedside manner is not as highly emphasized. There’s definitely a learning curve for many of them when it comes to that, but I think most of them do go on to adapt to our more personable style of patient care.Hope that helps to answer your question.Dr. Paul

SOAP notes are a crucial part of each client’s treatment. To write successful SOAP notes that help you make the most of each session, consider the following tips.Be concise: Your SOAP notes should be easy to read, so you can quickly communicate the information to other staff members or future physicians. Avoid overly wordy statements, and be as brief as possible. Use active voice and proper grammar. Also, ensure the spelling is correct.Be specific: Your SOAP notes should be both concise and specific. By including precise details, you’ll help prevent confusion and improve client treatment.Be mindful: Be mindful of others, such as staff members and clients, when writing SOAP notes. Clients may want to read their SOAP notes, so it’s critical to write clearly and appropriately, using language focused on their progress.Use third-person pronouns: Make sure the notes focus on the client and use third-person pronouns such as “he,” “she” or “they.” Avoid a first-person perspective and words like “me” and “I” to keep the notes professional and remove bias.Keep notes confidential: As a therapist, the law requires you to keep SOAP notes and other patient records confidential under the Health Insurance Portability and Accountability Act.Common Mistakes to AvoidHere are a few common mistakes to avoid when writing SOAP notes.Writing SOAP notes during visits: To give your client your fullest attention possible, avoid writing SOAP notes during each session. If you need to jot down a few things to help you remember what the client has said, you might keep them with your private psychotherapy notes. Enter SOAP notes into the EHR after each appointment, but avoid waiting too long, so the details stay fresh in your mind.Using judgmental statements: You’ll want to maintain professionalism in your notes and be as neutral as possible. That means avoiding overly positive or negative wording and focusing on giving accurate information. For example, instead of saying something such as, “The client, obviously lying, states their child could speak when they were 3 months old,” you should write, “The client reports their child could speak when they were 3 months old.”Naming others: Avoid including the names of family members, other clients or anyone else named by your patient. Instead, you might use initials to indicate the person your client is talking about. By only stating your client’s name, you make it clear to other staff members that your patient is the focus of the treatment. It also protects the privacy of others.Including unsourced opinions: In the Subjective section of a SOAP note, you might include others’ opinions that the client shares. For example, if your client states that their mother believes their symptoms are improving, write the word “mother” rather than saying “the client seems better.” It’s vital to show whose opinion you’re recording.Repeating yourself: In the Assessment section, do not rewrite what you recorded in the Subjective or Objective portions. Instead, include your analysis in this section, and describe the client’s progress and areas where they need to improve.Using acronyms and abbreviations: It’s best to avoid acronyms and abbreviations when possible to prevent misinterpretations. However, your agency might have a list of approved abbreviations you can use in your notes.Writing with adverbs: Adverbs describe verbs and typically end in “ly.” Adverbs reflect opinion rather than fact, so it’s best to avoid them. For example, rather than say a client spoke angrily, you might say the client raised their voice with you.Making assumptions: Avoid using words like “seemed” or “appeared,” as these demonstrate suppositions and can lead to confusion. Instead, include factual observations, only describing what the client physically does or says aloud.