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1
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2
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- Pre-round:
- Vitals: On the clipboard or soft chart in the Wallaroo by the patient’s
room
- Labs/Imaging: OACIS
- Radiology dictation line 2-6062
- SOAP Note: Big (hard) chart in the Wallaroo or at the nurses’ station
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3
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- Medicine:
- Long notes
- Big Assessment/Plan
- Surgery
- Short presentations
- Vitals, I/O, bowel movements or passing gas
- Remove bandage only on/after POD#2
- OB/GYN
- L&D:
- Big four (any exam room visit): Contractions? Vaginal bleeding? Loss
of fluid? Is the baby moving?
- Fetal status (FHT, variability, etc.)
- GYN, GYN-ONC, or Post-partum:
- Lochia: greater or less than menses?
- Otherwise like surgery note
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4
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- Pediatrics
- Psych
- Appearance --Behavior
- Speech --Motor
- Affect --Mood
- Thought content/process
- Perceptions
- Judgment/Insight
- Suicidal/homicidal ideation, hallucinations
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5
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- S: No SOB/CP overnight. 3 pillow orthopnea (improved from 4 at
admission). Pt feels swelling in feet has improved but still has to
elevate legs frequently. Pt walked halls s difficulty but did not
tolerate steps.
- O: T98.6 Tm99.3 HR87 RR14 bp114/69-129/78 I/O1800cc/4500cc FSBS 178-223
- PE: Gen – A&O x 3, in NAD; HEENT – PERRL, EOMI; CV – RRR, S3
present, no m/r/g, 2+ PE to mild calf (B); Resp – CTAB x mild crackles
@ bases (B), breathing symm c normal effort; Abd – s/nt/nd, NABS, no
HSMeg, no palpable masses; MS – MAEW, 5/5 strength UE/LE(B); Neuro – CN
II-XII intact, normal sensation to LT/pressure/temp (B), two-point
discrimination intact, gait normal, patellar and brachiorad DTRs 2/4
(B); Psych – affect mood congruent and appropriate
- Labs: CBC, BMP or CMP Rad: XR, CT, Echo, etc.
- A/P: 68 yo WM c CHF, HTN and DMII admitted for ↑ edema and DOE
- 1. CHF – previously class II but pt now symptomatic c mild exertion;
echo scheduled today to eval EF/cardiac fxn; pt on appropriate CHF
regimen at home; will continue aggressive diuresis c Lasix and consider
addition of digitalis at this time; cont low Na diet
- 2. HTN – currently on Lasix, BB and ACEI c good control, cont home meds
- 3. DMII – on glucophage at home c FSBS in 250-300 range; on SSI c FSBS
178-223 in house; will consult DM Ed to educate pt on diet/exercise as
well as recommend more appropriate home regimen; cont Q6H FSBS
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6
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- Pain well controlled on PO meds. +voiding + flatus/- stool. Tolerating
clears s N/V. Ambulating well.
- O: T97.9 Tm101.0 HR79 RR16 bp 104/67-123/78 I/O 2300/2150
- PE: Incision – c/d/i, no erythema; CV – RRR, no m/r/g; Resp – CTAB c
poor effort, mild crackles c deep insp; Abd – s/nd, appropriately
tender, NABS, ostomy site clean c gas in bag
- Labs:
Rad:
- A/P: 65 yo AAF s/p partial colectomy c Hartmann’s pouch & temporary
colostomy
- 1. Pain – well controlled, cont PO meds
- 2. Diet – pt tolerating clears c +flatus/BS, will advance to full
liquids and re-eval for bowel activity before adv to reg diet
- 3. LG Fever – likely due to atelectasis, pt to use IS Q1H; will get CBC
and monitor for other s/s of infection
- 4. Dispo – pt ambulating s difficulty, plan to d/c home c Home Health
services tomorrow; will see in 2 weeks for post-op visit, will schedule
re-anastamosis in 3-4 months
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7
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- Good examples of post-partum notes on OB/Gyn website
- Vaginal delivery and C/Section differ
- Access to website through WebCT while on rotation
- L&D: Q2H progress notes for women in labor
- Vitals include Fetal Heart Tones/Rate (FHT)/variability &
contractions/tocometry (e.g. Q4-5min) – found on monitors at bedside
- PE includes most recent cervical check
- If pre-eclamptic or r/o (HTN and +protein on urine dip), watch for labs
on OACIS (UA, Liver enzymes, 24 hr urine, platelets) and s/s (severe
headache, vision changes)
- If on Magnesium (MGSO4), monitor DTRs and RR closely for s/s of
toxicity
- Always give a woman’s “Gs and Ps” and weeks gestation: 24 yo G5, P3, A1
@ 23 5/7 wga
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8
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- Like Medicine notes except:
- “Subjective” largely dependent on parents
- Ins & Outs recorded as cc/kg (ins) and cc/kg/hr (outs) in younger
kids – for babies on formula, give Kcal/kg
- On Physical Exam
- Do parts of exam requiring silence FIRST (especially if child is still
asleep)
- Much of the exam can be done while playing with the child – be
creative! – parents and patients will be much happier
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9
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- Physical exam is Mental Status Exam (MSE) – different from MMSE
- Appearance (well groomed), Behavior (cooperative), Speech (pressured),
Motor (repetitive rocking motions), Mood (whatever patient says),
Affect (mood [in]congruent), Thought content (SI/HI, hallucinations),
Thought process (flight of ideas, tangential), Perceptions (seeing or
hearing things?), Judgment (decision making capabilities), Insight
(aware of illness?)
- DO NOT forget to ask about Suicidal/Homicidal Ideations (SI/HI)
- Labs are usually drawn only to monitor drug levels or other effects of
drugs (e.g. bone marrow suppression)
- Otherwise, SOAP notes are similar to other services
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10
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- PERRLA: Pupils equal, round, react to light and accomodation
- EOMI: Extra-ocular motions intact
- RRR: regular rate and rhythm
- CTAB: clear to auscultation bilaterally
- S/NT/ND, NABS: Soft, non-tender, non-distended, normal active bowel
sounds
- MAEW: Moves all extremities well
- DTR: Deep tendon reflexes
- QDay: Every day BID: Twice a day
- TID: Three times a day QID: Four times a day
- QOD: Every other day Q6H/Q6°: Every 6 hours
- QAC: Before meals QAM/PM: At morning/night
- Prn: As needed for (e.g. prn pain)
- c: with s: without x: except
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11
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- Rounds: Game time
- Make a copy of your SOAP note (do not take notes out of the chart)
- Present in order of your SOAP note or H&P
- Try to go by memory as much as possible
- After rounds:
- Write orders
- “Is there anything I can do to help you?”
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12
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- First Line - Medication
- Second Line – Instructions
- Ex: Sig 1 tab Q6H prn pain
- Drugs like antibiotics won’t have a prn indication
- Third Line - Amount to dispense
- Ex: #30 or Disp 30
- Some people put QS for “quantity sufficient,” but never do this as a
medical student
- Remember, if prescribing a controlled substance, spell the number out
(Ex: #30 [thirty])
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13
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- Up to Date
- MD Consult
- E Medicine
- PubMed
- Articles not necessarily covered in Up to Date
- InfoRetriever: for PDA
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14
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15
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16
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17
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18
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- Psych
- 2nd Floor Charleston Medical Hospital (above ER)
- VA
- 2nd Floor: follow the signs for Specialty Clinics
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19
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20
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21
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22
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23
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24
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- 5th Floor MUH: on L&D
- 4th Floor Children’s Hospital: OR locker rooms
- Rutledge Tower 1st Floor: Behind OR
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25
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Notes
