Need Help with Charting/SOAPs

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