Examples of student write-ups to be submitted for evaluation:
Guidelines for Writing Notes
- Write patient's name, unit number, and visit date on each sheet
- Write your name clearly. You should be willing to declare your identity and assume responsibility for your work. Clear writing of your name makes it easy for other providers to identify you. It is an important courtesy to the patient and to other providers.
- Many clinics utilize the SOAP format for outpatient notes:
- SUBJECTIVE means only what the patient tells you (e.g., symptoms, attributions, etc.) or what you know to have occurred in the past (e.g., a medication change you made based on a telephone conversation with the patient). Results of consults can be placed here or in the objective section. Do not indicate impressions or results of your physical exam in the subjective section.
- OBJECTIVE includes results of physical examination and interval test data.
- ASSESSMENT includes your interpretation of information in the previous two sections.
- PLAN includes what you are going to do about your impressions. Many physicians dictate/write the assessment and the plan together for each individual problem (as in the examples provided).
- Note that some clinics (including many at UNC) use the traditional headings for inpatient H&Ps (HPI, PMH, Meds, FH, SH, ROS, etc) for the outpatient notes as well. The HPI would be the equivalent of the “Subjective” section and the others can be considered to be part of the “Objective” section. You should utilize whatever format your clinic uses.
- In general, for follow-up visits, you do not need to list the complete past medical history. This should be clearly indicated on a master problem list. If the master list is not in the chart, consider making one after the visit. You should list all the history that is relevant to the current visit (either the acute complaint or the chronic conditions being addressed).
- Organize the "subjective" section by problems and be sure your problems reflect the patient's agenda and also what you identify to be the important problems that need to be addressed during the visit (e.g., the patient may not identify his high sugars as an issue, but you should include it in the subjective section). Use the appropriate medical terms for problems so that a one can quickly review the history of the problem by glancing at past visit notes.
- Be sure the problems in the "assessment/plan" section correspond to those listed in the subjective section.
- If there is a separate medication list, discuss with your preceptor if you, a nurse, or the preceptor should update this. If there is not a separate medication list, the patient's current medications should be documented in the note at least every other visit or whenever there has been an important interval change. Use generic names if possible and indicate strength of medication and how often patient is to take medication. For new prescriptions, indicate how many refills are provided. At many clinics, patients may obtain refills by telephone. A nurse often reviews the most recent visit note for information on what medications are being taken. If you are not clear in your notes, mistakes may occur.
- On every note, indicate specific plan for follow-up ("return to clinic in 2 weeks to see Dr. Smith").
- On every note, indicate name of the supervising attending ("seen with Dr. Jones").