Need Help with Charting/SOAPs

core0 · Feb 19, 2008

i'm an fnp student and am having a really hard time with charting. i was wondering if any of you experienced np's could recommend a book or something? my problem is with the soap note. for example in a pt in the office for a yearly exam, lab results, or follow up, i don't know what to write as the chief complaint or how to address what my plan will be unless something is wrong with them. in other words, i have trouble writing soap notes for healthy pts.
i learned from bates. its kind of the bible for h&p. hopefully you have something similar. when i moved it was one of two books that i didn't throw away.
http://www.amazon.com/physical-examination-history-taking-cd-rom/dp/0781735114
as far as history taking the chief complaint is what the patient says. ask the patient. its always good to know what they think they are here for. if they say yearly physical then put that under chief complaint. basically the purpose of a well visit is to:
screen for diseases
assess risk of future medical problems
encourage healthy lifestyles
update vaccinations
maintain a relationship with a doctor in the event of an illness
and yeah i stole this from here:
http://www.nlm.nih.gov/medlineplus/ency/article/002125.htm
obviously if they are peds then its different - ie growth curves, vaccinations etc. it helps if you have screening guidelines in some kind of preprinted template. one place where i worked used the t-sheet system:
http://www.tsystem.com/paper-charting-solutions/primary-care/features.asp
this is an example of a template. there is nothing to stop you from making your own to guide you in remembering all the steps. you'll find that after a while you don't need it.
i also seem to just have general trouble with charting. like if the pt has been in your office for 10yrs and has a heart murmur do you need to address it every time in your notes? or if they are a controlled diabetic and here for a sinus infection do you address the diabetes or just what today's problem is?
you have to find out what your office policy is on documentation. if someone has a murmur and it is benign then generally you only have to mention it if it changes. so, if you are seeing them for a cough then you probably should mention it in the pe but you don't have to mention it in the assessment. on the other hand if they are there for a yearly check up something like mvp - stable no change. then in the plan you can state something like mvp - new prophylaxis recommendations discussed. pt is low risk. no need for prophylaxis. your pe should always mention it if you listen to the heart.
the single problem once again depends on how your office prefers it. diabetes is probably a poor example since depending on the type and severity it may mandate medication changes during illness. on the other hand if they have hyperlipidemia there is no need to address it if they are there for a sinus infection.
another thing i do is when i'm talking with the pt. i'll write down stuff like, "has trouble sleeping" instead of "insomnia x 4days." or i'll write "numbness in feet" instead of "pedal parathesia." it's like my brain is so focused on what the pt is telling me that i have a hard time converting it into medical jargon.
any suggestions other than the obvious that i need more experience?

what you write down is fine. my notes resemble hieroglyphics with little arrows abbreviations and drawings. as long as it means something to you it doesn't matter (as long as you can decipher your own writing). for example instead of insomnia x 4 days i might write 0 sleep x 4d. whatever works for you. generally the less writing you do to convey the same information the better. i have a friend who was a court reporter before pa school. she does her notes in short hand. i'll never figure them out but thats not important. for me you are doing exactly the correct thing. you are focusing on what the patient is saying which is the important part. you have time later to convert it into medicine talk. it all comes with time.

good luck

david carpenter, pa-c

westcoastgirl · Feb 21, 2008

Bates and also Jarvis are my books for basics. I believe it's important that each SOAP note can stand on its own. For example you never know what note might be sent to the specialist, somebody is going to look at that along with the referral you've written.

If it's a patient you know and there's a lot of chronic conditions occasionally I chart "see previous note" but I almost always try to at least address the status of each condition, the meds, again because each of my notes have to be understandable to either another provider who's covering for me while I'm on vacation, or a specialist that I'm referring to.

I like to be as concise as possible while keeping all of the above in mind.

yellow finch, BSN, RN · Feb 22, 2008

I just picked up a book by Maldonado, Zuniga, & Uzelac entitled SOAP for Family Medicine. You might find some good information within this text on specific topics with details on all SOAP components specific to the clinical issue.

Check it out for a quick reference.

DaisyRN, ACNP · Feb 24, 2008

hi there,

i also struggled with what to write... not to write... and now that i am finished, i realize that i was making things much harder than it had to be (story of my life.) :) but here is a resource i used in school to make things easier:

http://meded.ucsd.edu/clinicalmed/oral.htm

also... with regard for the chief complaint. because i am working for a cardiologist group, we get a lot of consults for evaluating murmurs/abnormal ekg's etc. and so, if the patient absolutely has no complaint, i will put "history of murmur" or something along those lines. however, the best cc is in the patient's own words and brief. you'll figure it out.

good luck!

Dixiecup · Mar 4, 2008

I am taking the class right now that addressed just these issues.

I found that the soap charting for the NP is much more comlicated than the soap charting for an RN. It took me a long whle to get out of this mode and way of thinking.

They tell you to chart in soap format, but what they really want is charting in the H&P format and it took me a while to grasp this. But after a few critiquing from my instructors, I finally got what they wanted.

YOu just have to break it down into every system and address each one. YOu need to get a format to go by and follow it.

Your instructors should give you some insight. Mine are certainly not hesitant to do so. And the feedback IS helpful.

BChapp3182 · Mar 16, 2008

Thanks for the advice. I did purchase the book SOAP notes for family medicine and am finding that helps me greatly, especially when it comes to clinicals. Also great as a refrence/study aid. I'm starting to feel a bit more confident..