Advanced Pathophysiology

Clinician's Corner: Writing a Good Progress Note

Dr. Desai: Hey guys, Dr. Desai here from Osmosis. And I wanted to talk to you guys this week about how to write a really good progress note or clinical note. And I brought with me a little prop, so this is just to remind you what we're talking about today. And if you've written a note before you know why I'm holding this up, let's see if I can… There it is, S-O-A-P, subjective objective assessment and plan, SOAP or SOAP notes are what we call them sometimes. And it's just a shorthand to remember kind of what we should include in the note.

The subjective is what a patient tells you. Objective is kind of what you determined by yourself through physical exam, or labs or imaging. Assessment is kind of your thought process, what do you think is going on and explaining that fully. And a plan is just that, it's like, what are you going to do next? So this is a SOAP note format, it's pretty universal.

And so this is what we want to talk about today. What are my top three tips for writing a good note? And this is kind of over many years I've kind of started really thinking about it and come up with it. Let me dive into what I like to do, so my top three tips. Top tip number one, write a story. Keep in mind when a patient comes to you and they have a problem, whatever problem they might have, they'll say, "Oh, my hip hurt, and then I was walking and it hurt more. And then now I feel like maybe it's getting really, really bad." And then you ask them, "Oh, what do you think caused it?" "Oh, I think it may have been because I went to the gym and I was exercising." So you're kind of putting together a story and sometimes it's hard as a patient to kind of put the story in order, chronological order, they're kind of just telling you bits of this story.

It's your job in the history and physical, which is also kind of the subjective and objective part, to lay out the story and say, "Okay, look, we understand that you had kind of hip pain, but let's start with kind of going to the gym, and then the hip pain started maybe three days later. And then on physical exam or the assessment part, I noticed that it's hard for you to move your hip in a certain direction." So maybe that kind of gives you a clue as to what's going on. So that's telling a good story.

For example, same story, if you're not telling a good story, it'd be like, "Oh, a person had hip pain, and then a month ago they had a runny nose and it lasted three days. And then they recently traveled to New Zealand and they came back and they eat a lot of kind of fatty foods." It's kind of all over the place, right? That's not a good story. I think if you're listening to that story, you're like, "Well, what's going on? Where's the story arc? What's even happening?" If you're watching a TV show like that, you'd probably click away, right?

So tell a good story, write a good story, make it make sense logically, because what it does is it kind of feeds into the next parts of the history. You want to say, "Okay, so tell me more about the gym? What were you exercising? Where you exercising your arms, your legs?" When you're doing your history and physical, and you're writing down your SOAP notes, in your subjective and objective, you want it to flow very naturally, it makes sense. So it kind of builds up to a crescendo, which is your assessment.

So tip number two, remember that when you're doing the assessment, a diagnosis is a label. So it's very, very important, once you write down a diagnosis in your chart or you write in your assessment, I think this patient has, let's say depression or chronic fatigue, that label is going to stick with that person. They're going to go around, that patient chart's going to follow them. And so remember that that's not an easy label to kind of shake off. I'll give you a quick story, I had a patient who is vitamin B12 deficient. And in the chart it said things like, "Patient is depressed. Patient is kind of feeling headaches." And because it said those things, every time the patient said, "Oh, I feel really fatigued or tired." People just said, "Oh, well, in the chart it says diagnosis, depression. So that's probably what it is." And they didn't really think or given any kind of value.

And so when you write your assessments or write your diagnosis, every other doctor is going to see that and they're going to kind of think in the same way. So you're really cheating that patient out of giving them a fair shot at getting the real diagnosis. So when you write your assessment, think about all sorts of things, like what's the worst case scenario? What is the full differential of what could be going on? And if you're not sure about something, you can add that in your assessment and say, "Look, this seems possibly to be depression, but other things that we should really consider would be causes like hypothyroidism or vitamin B-12 deficiency. So just writing that out, and even if you don't have the answer, just saying there could be other causes or something about this doesn't make sense, is really, really important. So just make sure you put your full assessment in there so you don't cheat someone out of getting the right diagnosis, maybe down the road.

All right, next. The third tip then, make a specific plan. Not just like, plan to lose weight, but maybe reduce soda from three times a week to one time a week or start drinking a healthy smoothie for breakfast and maybe even look up a recipe with a patient. So when you're doing the plan, I want you to be very specific. So say things like, "Hey, this patient has agreed to going down on their cigarettes from 20 cigarettes to 10 cigarettes a week, very, very specific. And I'll tell you why, when I started writing SOAP notes, I used to think, "Oh, you know what? A SOAP note is a way to communicate with other doctors and nurses and pharmacists my thoughts." That's what I thought.

And that's true, but then about a year or two later I started getting meetings with people in the hospital that said, "Hey, we want you to write your SOAP note so that it actually makes sense for insurance companies, for the EMR." And so they wanted to check all these boxes and I thought, "Oh, okay. So I guess the SOAP note is a legal document, a business document." So that we have to communicate with insurance companies what we're doing so we get paid. So I thought "Okay, that's what a SOAP note is for." And then as I kind of went on, I realized, actually, it's not just that, it is that, but it's also something more, it's also a contract between you and your patient. It's a trust, you're saying to them… And this is what I do now with my SOAP notes, I read my SOAP note back to my patient. At the end, I'll say kind of, just quickly highlighting the things that I think are important.

And then when I start a new visit, let's say see them in a few months, I read it again and say, "Hey, last time what we talked about was this, this, and this, is that your understanding?" And they say, "Yeah, that's about right." And they can kind of fill in the gaps too. So I really want you to think about your progress notes as a contract between you and your patient. And the goal of a good SOAP note is to A, get the information, right? Again, writing a good story, number one. Number two, make sure that the assessment is truly thought through, because the assessment or diagnosis is a label so make sure you think about that. And number three, make sure that when you're writing a plan it's very specific. So again, number one, write a story. Number two, remember that your diagnosis is a label. And number three, make sure that you write a very specific plan. I'll see you again later, bye-bye.

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