Progress Notes

April 23, 2003

Dr. Karl

Accurate notes are an important, but sometimes unsung, part of the patient care process. In order to properly convey critical data, interns and residents must make intelligent choices about what information is essential, and what is superfluous.

This issue, Q Fever!’s I&R correspondent, Dr. Karl Newman , teaches you a systematic approach to: Progress Notes .

Hiya, gang! It sure feels good to be back. I missed ya’s! And ya caught me in a good mood. That’s ‘cause today, we’re touching on a subject that’s near and dear to my heart. You guessed it! Progress notes. Without ‘em, your day might go a lot faster, but stop writing ‘em for a week or two, and you’ll discover what I did: Just because there ain’t been no progress, doesn’t mean you don’t need a note.

So here’s some tasty tips from Unkle Karl:

1. Know Your Notes.

Who dat? It’s lil’ ol’ me, sayin’ you can’t write a good progress note, till you know what kinds of progress notes there are. The most basic type of note is the SOAP note. That’s in comparison to other, more acidy types of notes. Then, the next three notes just happen to be “do-re-mi,” and if you know these, well, heck, you can sing most ... aw, heck with it. Just a little light humor for ya before the heavy stuff, ok?

Let’s explore SOAP notes a little ...

2. SOAP It Up, Baby.

You mean it, honey? Sure I do. Each letter in “SOAP” stands for a different word. Make sure you understand that little-known fact before proceeding, otherwise the rest won’t make much sense!

The Subjective part is where you write how you’re feeling that day. Confident? Angry? Sad? Bemused? Discuss your opinions on current world events here too, if you got ‘em. It doesn’t really matter, ‘cause no one reads this part.

In the Objective section, you’ll be documenting your physical examination. Vitals, waist-to-hip ratio, hip-to-breast ratio, and hand-foot-mouth ratio all go here. A small police-type sketch is useful, too. Don’t hesitate to get a small policeman to help you with this.

Another thing to remember about the Objective section is to use the right terminology. If a female patient is in a frenzy and out-of-control, don’t use the word “hysterical.” That’s because its root is hysterus, meaning “uterus” in Latin, which might reveal you as sexist and misogynist. Use “histrionic” or “melodramatic” instead.

Next up, the Assessment. In many ways, this is the most important part of the note. It’s pretty self-explanatory, if you ask me. Assess the situation. Check to see that all major fire escape routes are clear. See if the meds in the crash cart are all up to date. What are your chances of making it out alive? Also, this is your chance to show how good you are at differentials. And you thought you’d never get to use AP Calc!

Lastly, we come to the Plan. What are your plans after residency? Doing a fellowship? Going into private practice? Getting sent back to China? A short essay on why you became a doctor is appropriate. Keep it concise and to-the-point! Potential employers have better things to do than to hear you ramble on and on about yourself. The nerve of you!

3. Stay On The Up And Up!

Are you for real? Yesirree Bob! Medicolegal aspects of note-writing are more important than ever. Every thing you write, draw, dribble, or drool out onto a chart can be used against you in a court of law. That includes things that you started writing, but then tried to erase or cross out. The simplest, and most effective, thing to do if you make a mistake is to draw one line through it, then carve your initials next to it using a small pocketknife. For larger mistakes, do what I do: carefully cut out the offending area using a pair of scissors.

It’s also important to document every conversation you have with the patient, whether they’re at the bedside, at the driving range, or in your one-bedroom apartment. I like to also document conversations I have about the patient with colleagues, friends, neighbors, and people in line at the post office. This kind of attention to detail will impress lawyers and juries alike, if and when you’re hauled off to court!

Holy Mackerel! Look like we’re out of time, ladies and gents! All I can say is, I’ve really enjoyed our time together, and I hope you have, too. Keep those pencils sharpened! And until next time,

“Just tell ‘em Dr. Karl sent ya!”

Remember: Quality Without The Q Is Just Uality!