How To Write A History/Physical Or SOAP Note On The Wards

Writing notes is one of the basic activities that medical students, residents, and physicians perform. Whether it is a detailed pediatric SOAP note or a brief surgery SOAP note, this is how we communicate with each other, now and for future reference. Someone may need to read your note months or even years from now, so you want to make sure your note is written well.

The basic format for a note is the SOAP note. SOAP stands for:

S - Subjective: any information you receive from the patient (history of present illness, past medical history, etc)

O - Objective: any data, whether in the form of a physical finding during your exam, or lab results
A - Assessment: diagnoses derived from the history and objective data
P - Plan: what you intend to do about the diagnoses from your assessment

Pretty simple, right? However, Day 1 on your first rotation comes around, and you're asked to write a note. You write down "SOAP" but... then what?

Well, if it is the first time you are seeing a patient, you should write a full history and physical (H&P). The H&P should include the history of present illness, past medical history, past surgical history, allergies to meds, current meds, relevant family history (e.g. "Mother and Sister had breast cancer"), and social history (tobacco history in pack years, alcohol, drugs, etc). For HPI, a helpful mnemonic is OLD CHARTS:

O - Onset: when the problem began

L - Location: what area of the body is affected
D - Duration: how long has it been hurting, is the pain continuous or intermittent

CH - Character: words to describe the problem (dull, sharp, burning, stabbing, throbbing, itching, etc)

A - Aggravating / Alleviating Factors

R - Radiation

T - Temporal: is there any pattern to the pain, such as always after meals

S - Associated Symptoms

It is also a good idea to ask about previous episodes of a similar pain, or any relevant family history.

Anyway, back to the SOAP note. Assuming you are familiar with the patient, the SOAP note details what has occurred since you last saw them, typically the previous day. You want to note any changes in their condition or treatment. If nothing has changed, you can write "Did well ON (overnight). Tolerating food and medications. NAD (no acute distress)" or something along those lines. The objective portion should be their latest vital signs, as well as their "ins & outs" such as IV fluids, UOP (urine output), BMs (bowel movements). The objective portion also includes any new lab or study results. The assessment is generally a restatement of what the patient's ongoing diagnosis has been (e.g. "This is a 37 year old female, POD (post-op day)# 3 after a lap chole (laparascopic cholecystectomy)"). The plan describes what you want to do for the patient next. In the hospital, it's a good idea to run through all the major systems in your head and try to think about what is going on for each one. Here is a simple list: Airway/Breathing, CNS, CV, Endocrine, Fluids, Heme, ID, Renal (UOP), Social. Depending on the rotation you are on, other systems may be more relevant. If nothing comes to mind for a system, there is usually no need to mention it unless your residents or attending specifically want you to.

That's pretty much it. After writing several of these notes, and seeing the other notes in a patient's chart, one starts to develop their own style of writing them, so don't be too concerned about sticking to one particular format as long as you find one that suites how you think while covering all the pertinent information.

For more basic information on how to ask certain histories or perform focused parts of the physical exam, I recommend Bates Guide to Physical Examination:

The book has good illustrations and simple explanations of why doctors perform certain exams. The version above is pocket-sized, which is handy for carrying around in your whitecoat. However, if you are looking for detailed information about the physiology behind certain parts of the physical exam, a physiology textbook reference may be more useful. Still, Bates is the standard for learning how to do a history and physical. Many of my attendings still have the book on their reference shelves from back when they were in medical school!

Updated 20200228

Dale Dubin, EKGs, Medicine, and Race

As you might recall, this blog has previously investigated the background into the mysterious Dr. Dale Dubin. However, as mentioned last time, regardless of Dr. Dubin's extracurricular activities, the book "Rapid Interpretation of EKG's" is a good introduction to how to read EKGs. However, as one peruses the book, other interesting findings come to light. Take a look at a page from the 2nd edition, reproduced below:

There are but two interpretations of this post:

1. Dale Dubin is using the stereotype of African Americans having "rhythm" to emphasize a trivial point about the cardiac rhythm.... racist!

OR

2. Everyone has a tiny black man that lives inside their heart. This tiny black man (I'll call him "Mr. Biggs") is very musical. Mr. Biggs loves to play on his drums, and by doing so, he keeps our heart ticking, kiddos. Thank you, Mr. Biggs. You are a true hero.

I don't know about you, but I believe #2 is the proper interpretation. I think the interpretation you choose to believe in says a lot about you. Which one seems right to you?

Don't believe me? Check out the book for yourself: 

Want more? Check out: Dale Dubin: Pornography and Prison

Updated 2015-12-07

What About Google Health And Electronic Medical Records?

The New York Times has an article about Google and Microsoft and their approaches to healthcare. After reading that, I decided to read a Google Blog entry about their product managers' thoughts on healthcare. It seems that both large firms see a big opportunity here, especially Google. I must admit, I am biased towards Google based on having used their products and what I have read about their corporate culture. However, while generally a proponent of such technology, I wonder how serious privacy issues are in this arena.

Perhaps this is obvious, but I think applying IT to healthcare should be a national priority for a plethora of reasons. As a med student, I am trained to take a fairly routine history, which includes history of present illness, past medical/surgical history, drug allergies, current medications, family history, and social history. A lot of this information is constant over time and occasionally can be crucial for the patient's care. However, patients are not the best historians. They forget the names of their meds, they forget surgeries they've had, they forget even why they came in sometimes!

A health record that is owned by the patient can help remedy this. Imagine an international standard for a health record. I'll call it a "Portable Health Record" or PHR, for short. In digital format, your .phr file would contain all of this information in a standardized format. Viewers would help you easily access and understand the information, which you could update as necessary. The same would go for the physicians whom you would give access to. By having one standard format, if you ever move or switch physicians, your health record would stay intact, and your new physician would be familiar with how the information was stored. Simple, right?

However, privacy is a major issue that shatters this simple view. People would worry about insurance companies or others who may not have your best interests getting their hands on this information. Such information could be used to exclude patients from healthcare plans, or to target them for direct marketing. One can imagine even worse possibilities.

But, how realistic is this? I believe that with proper safeguards, such as data encryption and appropriate permissions systems, this risk is really just a straw man. We are already exposed in many ways, by using online banking and credit cards. While there are real risks involved with those activities, millions of such transactions occur everyday. As the Google article alludes to, if we can use IT to reduce medical error, I think from society's point of view, this benefit outweighs the risk/cost of exposing some to an invasion of privacy. Perhaps I feel that way since I have no personal experience with identity theft, but I think if people are responsible and the technology is developed appropriately, it will benefit patients, physicians, and society.

Rev 20200228

The Truth Behind "Rapid Interpretation of EKGs" by Dale Dubin

Many students are puzzled about how to interpret EKGs. They are often directed to "Rapid Interpretation of EKG's" by Dale Dubin, a supposedly classic introductory text on how to read EKGs. The book's tone is conversational, and one quickly comes to realize that Dr. Dubin believes he is God's gift to reading EKGs, as evidenced by his:

• thanking himself in his acknowledgements (ok, fine, maybe it was his father who had the same name, but there's no way to distinguish this in the text)
• using his own quote as an introductory quote for the book, but referring to himself as "DD" to make it seem more mysterious
• just his overall tone
• offering a car to anyone who read the copyright notice in one of the editions and mailed in.

That last one sounds too good to be true, right? And all this makes you wonder, who exactly is Dale Dubin? Well, according to this article on snopes.com:

"But sometimes lore manages to intersect with real life when a legend
long extant is duplicated in actuality. (Folklorists term this
phenomenon "ostension.") In 2001, Jeffrey Seiden, a third-year medical
student at Yale University, was studying his electrocardiography
textbook when he happened upon the following message tucked away in the
book's copyright notice:

Congratulations for your perseverance. You may win the car on page 46 by
writing down your name and address and submitting it to the publisher.

Dr. Dale Dubin had inserted the note into his 50th printing of his
"Rapid Interpretation of EKGs," putting his classic Thunderbird up for
grabs. Of the 60,000 who last year bought the book containing the offer,
only five spotted the hidden message and contacted the publisher with
news of their find. The five names were placed in a hat, and Jeffrey
Seiden's was chosen at random. The 1965 Thunderbird convertible was
delivered to him on 4 December 2001 by Dubin's daughter, who drove it to
Seiden's school."

Nice story, right? But guess what:

Yale officials heard of the contest only at the last minute, but they
allowed the award to be made on campus and helped with some of the
publicity. Since then, however, Yale has done what it can to distance
itself from the affair. When questioned about the award, Karen Peart, a
university spokeswoman, told the /Hartford Courant/: "This is not a Yale
matter."

The school's reluctance to be associated with Dubin stems from
revelations about his past: Dubin is an ex-convict whose medical license
was revoked after a 1986 conviction in Florida on federal drug and child
pornography charges. He was sentenced to five years in a federal prison
and was released in 1989 after having served 3½ years.

Yep, that's right: to quote The Big Lebowski,

Dubin's a pederass.

But, what the heck, it's a good book. You should still buy it:

Updated 20200228

Atul Gawande and "Better" - A Medical Student's Review

As a med student, and one who had recently completed his surgery rotation, I feel I had a relatively unique perspective while reading this book, as compared to most readers. It was also interesting to read this book and gauge my reactions, relative to how I reacted when reading Gawande's prior book Complications. When I read Gawande's first book, I had not yet started medical school, and had at best, an educated lay person's background. I found the stories there intriguing and confirmed my romantic notions of medicine. This book mirrors my own internal evolution to a certain degree. Less romanticized, more practical, it discusses more of the everyday issues in medicine, ones that I see often as a student out on the wards. People do not wash hands as much as they should, the science of efficiency has not been applied to medicine, and the book takes us all to account for that. While medical technology has become remarkably efficient and high-tech, the actual delivery of medicine leaves much to be desired. Anyway, I digress.

The book reads very much like Complications. Gawande presents 12 separate essays about different aspects of healthcare, from the advances in obstetrics to the lack of investment in studying the provision of care to the doctors who are involved with executing prisoners who have been given the death penalty. Unlike Complications though, Gawande injects more of his own personal opinions after a more dispassionate presentation of each subject. The writing is sparse and clear, making it easy to read. Some of the chapters read almost like a medical Profiles in Courage

However, unlike Complications, this book did not leave me feeling as enthralled. Perhaps I have become jaded by medicine, or perhaps the topics of 'improving' medicine are simply not exciting. I think I liked Complications better simply because it dealt with more esoteric issues. While I agree with Gawande that the topics covered in Better are more important and can potentially affect many more people, the cases covered in Complications are simply more intriguing, such as the woman with necrotizing fascitis, or the reporter who sweat too much.

Overall: 9 out of 10 - a good engaging read that covers many important and relevant topics.

Updated 2015-12-06