Download Expectations For Chart Notes and more Study notes Medicine in PDF only on Docsity!
DEPARTMENT OF FAMILY MEDICINE
Expectations For Chart Notes
Chart Notes
Key issues for outpatient and inpatient chart notes:
The patient’s medical record, often called a chart, is a legal document. Be bold in your oral presentations but conservative in your charting. Write fluently and legibly; do not leave blank lines in between your text.
If dictating, do not speak in full sentences but in point form. Avoid extraneous words but make sure your meaning is clear.
If you make a mistake, cross out the unwanted park part, whether it is one word or several sentences, then write “error” beside the mistake and initial it. Those who read and examine medical records must be able to see mistakes and know who is responsible for crossing a word or sentence out. DO NOT SCRIBBLE WORDS OUT.
For any handwritten note, always sign your name and then print your name, along with the proper credential i.e. John Smith—John Smith FMR1.
For a dictated note where your name has been typed—you may initial your name Always work with an up-to-date problem list at the front of the chart
SOAP Notes
Done for patients seen in an ambulatory or clinic setting. Not necessary to use complete sentences. Be clear and to the point. If dictating or writing, the structure is always the same.
Start with the date Indicate the major reason (or reasons) for the visit in a title
SUBJECTIVE This section contains information you have learned from the patient or from people caring for the
patient.
Average length 2-3 lines Deal with patients’ symptoms.
Include a description of concerns or complaints.
When appropriate, your note should refer to onset, duration, location, severity, relieving or aggravating factors, associated symptoms, pertinent negatives gathered in the history. As well, comments on patients’ feelings, fears, impact on functioning and patient expectations could be noted.
Include pertinent information contributed by family members.
OBJECTIVE
Deals with clinical findings and patients’ signs.
These include things you, as an observer, can: see, hear, touch, feel, or smell. Your note should refer applicable: important vital signs, physical examination findings (key normal and abnormal findings), mental status, observations (such as gait), lab data, imaging results, and procedure results. Limit physical exam findings to appropriate organ system(s).
For patients on multiple medications, periodically summarize the medications they are receiving or refer to an updated medication list.
You may refer to pertinent past diagnosis, as well as target values for lab tests. You may consider commenting on how the patient has responded to past treatments.
ASSESSMENT
Your diagnosis / diagnoses of the patient’s condition(s) Include what you feel is the patient’s differential diagnosis and why. You may find it easier, when there is more than one issue. Comment on any health maintenance issues that were addressed.
PLAN
Base your plan on your assessment. How will you treat each problem?
List changes in existing management strategies as well as new medications, lab tests ordered, procedures you want done, and patient referrals to be made.
Be specific with medication including, at the minimum, name and dose. Use generic names of drugs. Comment on recommendations for patient follow-up.
A/P
When multiple problems exist, consider combining assessment and plan—discuss each problem with its specific plan sequentially.
SUMMARY
In summary, a SOAP note should briefly express the following: Date and purpose of the visit
Start you note right after the last note in the chart so it will be chronological.
Date and time your note—it is helpful to start with the number of days the patient was spent in hospital so far.
Comment on each active problem
Always sign your name and then print your name along with the proper credential i.e. John Smith—John Smith FMR
