Soap note women’s health

From the professor

Try to incorporate the Q&A portion of your subjective data and rewrite it into your HPI and ROS, Example- “When did your symptoms start…, pt answered: 3 days ago” , “Do you notice any vagina discharge or pelvic pain? No, I do not have pain but I notice some discharge.”, “Does the discharge have any smell? Is it thick, or thin? What color is it? It does have a smell, and it is watery discharge.”

You can rewrite this in your HPI.

“Pt in clinic complaining of vaginal discharge that approximately started 3 days ago.. Pt states she is having a thin white vaginal discharge with odor”

ROS

Gyn- denies pelvic pain, reports positive watery vaginal discharge, reports positive vaginal odor …

Start transforming your Q&A into a narrative format for your SOAP note. This is how SOAP notes are documented in clinic and your notes will start to look like them as well. You may also notice that it takes you lesser time to write your notes because you are not typing the questions. For one of the items on the prompt, it asks “what additional questions would you ask”, I am expecting that you have theoretically asked your patient and that I am reading only the narrative version of your conversation.

Also

1. Answer the chart/s completely and in your own words. Do not copy and paste information from the text or websites. I understand some treatments and characteristics cannot be paraphrased, but even typing/writing them yourselves VS using the copy and paste tool is a way to learn the information. Do not forget to cite your source. If there is any data that catches my attention, I look at your source to see where you found that information.

2. Your response to the prompt NEEDS to be in a SOAP note format, as if you are documenting this theoretical visit. I need to see the CC, HPI, Hx, ROS (please see previous announcement in week 1). If you are including questions to ask, make sure those answers are written INSIDE your HPI or ROS

3. Make sure your ROS and Physical Exam is NOT a copy paste from a source. I do expect a thorough exam–but the exam and the ROS need to relate to what is appropriate to the visit. Example- a patient comes in with a complaint of vaginal discharge and the exam included- visual acuity 20/20- visual acuity is not performed on a visit like this. This signals me that you took a template from a source and did not personalize it.

If you are using a template, ensure that you rewrite the template, edit the template, and make sure it relates to the prompt. I don’t mind having heart and lungs and the basics examined, but if you are including the webber test and rinne test in a vaginal discharge visit- it is obvious that you took this template and did not edit it nor tailor it to your patient.

4. Make sure that your medication includes the dosage and how you want the patient to take the medication (sig). Make sure your plan is specific- example- your patient is having irregular bleeding and you ordered an “ultrasound”. What is this ultrasound for? What type of ultrasound- abdominal, transvaginal, breast? I need to see the type of diagnostic test that you want to order and why? Again, this shows me your knowledge. Same with medication, you diagnosed your patient with a vaginal infection and your treatment plan cannot be “give antibiotics”. Which antibiotics? How much? Why? Again, this mimics a patient visit where you diagnose patient with an infection and the prescription you give to the pharmacy is “antibiotics”. This will not be accepted.

5. DO NOT PLAGIARIZE. DO NOT COPY from a source and not paraphrase nor cite the source. I understand a lot of you use a template in the ROS and physical exam, I understand that, but it MUST be tailored to the patient. These DBs and SOAP notes mimic a theoretical patient and we must work with integrity and honesty. False documentation is a crime, you can lose your license and can be charged with crime. Let us stop this practice now in school so we will not carry this over in the real clinic world.

6. If I am asking you to rewrite your initial response- this is my way of giving you a chance to correct some mistakes or to include missing data. This rewrite does not count as a peer response. I still expect you to respond to 2 peers on 2 separate days and one of the responses needs to be about the other prompt.