Clinician's Corner: Writing a good progress note

Summary

In this video, Dr. Decide from Osmosis provides valuable insights into writing an effective SOAP note. He explains the importance of telling a coherent story, carefully considering diagnoses as labels, and creating specific, actionable plans. By focusing on logical flow in the subjective and objective parts, addressing all potential diagnoses in the assessment, and outlining detailed steps in the plan, healthcare providers can ensure clear communication with patients and other providers. Dr. Decide emphasizes that SOAP notes are more than just a legal document—they are a contract that fosters trust and improves patient care.

Takeaways

• 😀 Write SOAP notes to communicate effectively: Subjective, Objective, Assessment, and Plan.
• 😀 The subjective section captures the patient's personal account of their symptoms or concerns.
• 😀 The objective section focuses on observable findings, such as physical exams and test results.
• 😀 The assessment section should detail your clinical thinking and diagnosis, considering all possible options.
• 😀 A diagnosis is a label that stays with the patient, so make sure to consider all possibilities in your assessment.
• 😀 Writing a good SOAP note involves telling a clear and logical story, with details that flow naturally.
• 😀 Use a differential diagnosis when you're unsure, explaining other potential causes or conditions.
• 😀 The plan should be specific and actionable, with clear goals and steps for the patient to follow.
• 😀 Think of SOAP notes not only as communication tools but also as contracts that build trust between you and your patient.
• 😀 Reviewing previous SOAP notes with the patient helps ensure mutual understanding and continuity in care.

Q & A

What is a SOAP note?

A SOAP note is a structured format used in clinical documentation to organize patient information. It stands for Subjective, Objective, Assessment, and Plan. This format helps healthcare providers communicate effectively and document patient encounters.

What does the 'Subjective' section of a SOAP note involve?

The 'Subjective' section includes information that the patient tells you about their symptoms, concerns, and history. It captures the patient's perspective of their condition.

What should be documented in the 'Objective' section?

The 'Objective' section contains the healthcare provider’s observations and findings, including results from physical exams, lab tests, or imaging studies. This section is factual and measurable.

What does the 'Assessment' section in a SOAP note entail?

The 'Assessment' section is where the healthcare provider analyzes the information gathered in the subjective and objective sections. It includes the provider’s diagnosis or differential diagnoses based on the patient’s condition.

How does the 'Plan' section differ from the other sections of a SOAP note?

The 'Plan' section outlines the next steps in managing the patient’s condition. It includes treatment strategies, further tests, medications, and follow-up plans. The plan should be specific and actionable.

What is the importance of writing a good story in the SOAP note?

Writing a good story helps to create a logical and chronological flow of the patient’s symptoms, making it easier to understand the situation. It ensures that the information is clearly documented, aiding in diagnosis and treatment planning.

What does Dr. Decide mean by saying a diagnosis is a label?

Dr. Decide emphasizes that once a diagnosis is recorded in the SOAP note, it becomes part of the patient's medical record and can influence future decisions. It’s important to consider all possible diagnoses and not just settle on the first one.

Why is it important to consider a differential diagnosis in the 'Assessment' section?

Considering a differential diagnosis ensures that all possible causes of the patient’s symptoms are explored. This prevents misdiagnosis and ensures that the patient receives the correct treatment.

Can you provide an example of a specific plan in a SOAP note?

A specific plan could involve clear actions such as 'reduce cigarette intake from 20 to 10 per week' or 'start drinking a healthy smoothie for breakfast'. These are concrete steps that the patient can follow to improve their condition.

What did Dr. Decide mean by the SOAP note being a contract between the healthcare provider and the patient?

Dr. Decide refers to the SOAP note as a contract because it outlines the shared understanding between the healthcare provider and the patient regarding their condition, diagnosis, and treatment plan. It’s a formal way of documenting mutual goals and expectations.