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Marcy's soap note powerpoint1
1. ZEN AND THE ART OF SOAP
NOTE WRITING
A presentation on why SOAP notes matter, and
how yours can be the best
By: Marcy Rosen
MD and avid SOAP note reader
2. In this presentation you should learn:
¨ Why we write notes on patients
¨ The 4 points of a SOAP Note
¨ Information most relevant to post-partum SOAP
notes
12. Assessment: Post Partum Patients
¨ Examples:
¨ 31 y/o G3P3 post-operative day 1 after primary c-section
for fetal intolerance to labor
¨ 28 y/o G1 P1, post partum day 1 after NSVD
¨ 32 y/o G3 P2012, post partum day one after SVD, severe
pre-eclampsia
¨ 19 y/o G1P1 day 3 s/p NSVD with chorioamnionitis, now
resolved
13. Plan
¨ 1. Link the subjective and objective to the
assessment
¨ 2. Address the next
step in the patient’s
clinical course
14. Important Points:
¨ Your note conveys the snapshot of a patient at a
moment in time
¨ It is important to limit your note to pertinent
information
¨ If you include something outside of normal limits in
your subjective or objective, it needs to be
addressed in the assessment and/or plan
16. Most importantly!!!!
Write your note as if
the next person
reading it has NO IDEA
about the patient. Your
note should convey
everything they need
to know.