Soap Notes: 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

Most of us are taught a formula - it’s called a “SOAP” note!S - subjective - This is the client’s presenting problem, as they are reporting it at this time. What are they still struggling with? What are they experiencing? What are their symptoms like?O- objective - This is what the therapist observes, results of testing/assessment, or what is happening from the therapist’s perspective.A- assessment - Possible reasons for what is happening above, and why. Also, we always include a note about suicidality in this section - for both legal reasons, and as a prompt to be sure to think about this on a regular basis, since clients who are suicidal don’t often present in “stereotypically depressed” ways.P - plan - What the therapist plans to do to treat the problems above, how they will proceed to do it, and why.I would write this immediately after each session. If you wait until end of day, you lose a lot of nuance and detail…if you do it during session, it’s very distracting and (in my opinion) disrespectful.I would schedule sessions for 50 minutes, and use the last 10 minutes to write/type/dictate these notes in great detail.Basically the formula helps to organize your thoughts, pay attention to client symptoms, be sure to you are reviewing the right things, and that you always have a plan moving forward.While hospitals almost always require a format, many therapists stray from this in private practice.I always kind of liked it, honestly.

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