Handout 5

Progress Note (SOAP)

Note Date/Time: when you saw the patient—NOT when you wrote the note

Title of Note: Medical Student Progress Note for service

Subjective:
o focused history/ROS
o overnight events
o how patient doing with known problems
o any new issues?
o NOT a place to recap HPI, hospital course
Objective:
o 24 hours vitals summary (include I&O)
o KEY medications (if autopull in meds will have huge, unhelpful list)
o focused exam (if you didn’t check it that morning don’t include it in
your note, e.g. checking ears)
o current/NEW results for imaging and labs
o NOT a place for all results ever done on patient. If NOT new info it
shouldn’t be in daily note.
Assessment:
o what do you think is going on with the patient
§ differential if no known diagnosis
§ for complex patient organize by PROBLEM or SYSTEM
o improving/stable/worsening
Plan:
o what are you going to do today for this patient
o PROBLEM or SYSTEM based for complex patients
o do NOT repeat your assessment
o NOT a summary of hospital course and things that have already been
done

Signature: Name, role and contact info REQUIRED

Handout 5
Progress Note (SOAP)

Note Date/Time: when you saw the patient—NOT when you wrote the note

Title of Note: Medical Student Progress Note for service

Subjective:
o focused history/ROS
o overnight events
o how patient doing with known problems
o any new issues?
o NOT a place to recap HPI, hospital course
Objective:
o 24 hours vitals summary (include I&O)
o KEY medications (if autopull in meds will have huge, unhelpful list)
o focused exam (if you didn’t check it that morning don’t include it in
your note, e.g. checking ears)
o current/NEW results for imaging and labs
o NOT a place for all results ever done on patient. If NOT new info it
shouldn’t be in daily note.
Assessment:
o what do you think is going on with the patient
§ differential if no known diagnosis
§ for complex patient organize by PROBLEM or SYSTEM
o improving/stable/worsening
Plan:
o what are you going to do today for this patient
o PROBLEM or SYSTEM based for complex patients
o do NOT repeat your assessment
o NOT a summary of hospital course and things that have already been
done

Signature: Name, role and contact info REQUIRED

Handout 5
Progress Note (SOAP)

Note Date/Time: when you saw the patient—NOT when you wrote the note

Title of Note: Medical Student Progress Note for service

Subjective:
o focused history/ROS
o overnight events
o how patient doing with known problems
o any new issues?
o NOT a place to recap HPI, hospital course
Objective:
o 24 hours vitals summary (include I&O)
o KEY medications (if autopull in meds will have huge, unhelpful list)
o focused exam (if you didn’t check it that morning don’t include it in
your note, e.g. checking ears)
o current/NEW results for imaging and labs
o NOT a place for all results ever done on patient. If NOT new info it
shouldn’t be in daily note.
Assessment:
o what do you think is going on with the patient
§ differential if no known diagnosis
§ for complex patient organize by PROBLEM or SYSTEM
o improving/stable/worsening
Plan:
o what are you going to do today for this patient
o PROBLEM or SYSTEM based for complex patients
o do NOT repeat your assessment
o NOT a summary of hospital course and things that have already been
done

Signature: Name, role and contact info REQUIRED

Handout 5
Progress Note (SOAP)

Note Date/Time: when you saw the patient—NOT when you wrote the note

Title of Note: Medical Student Progress Note for service

Subjective:
o focused history/ROS
o overnight events
o how patient doing with known problems
o any new issues?
o NOT a place to recap HPI, hospital course
Objective:
o 24 hours vitals summary (include I&O)
o KEY medications (if autopull in meds will have huge, unhelpful list)
o focused exam (if you didn’t check it that morning don’t include it in
your note, e.g. checking ears)
o current/NEW results for imaging and labs
o NOT a place for all results ever done on patient. If NOT new info it
shouldn’t be in daily note.
Assessment:
o what do you think is going on with the patient
§ differential if no known diagnosis
§ for complex patient organize by PROBLEM or SYSTEM
o improving/stable/worsening
Plan:
o what are you going to do today for this patient
o PROBLEM or SYSTEM based for complex patients
o do NOT repeat your assessment
o NOT a summary of hospital course and things that have already been
done

Signature: Name, role and contact info REQUIRED

Handout 5
Documentation Do’s & Don’t’s

DO

• Start from scratch

• Keep it simple and relevant

• Focus on YOUR questions and actions in the S and O sections

• Document and INTERPRET NEW studies only (not just report)

• Remember to click Refresh

• Make sure Note Date = Date of service

DO NOT

• include the HPI in daily progress notes

• pull in all labs and radiology

• repeat Assessment in Plan

• document what you didn’t do (history or physical)

• COPY FORWARD unless prepared to do significant editing each day

• copy and paste from someone else’s note

• Expect the EMR to do the work for you. “1 click and note’s done”

EMR ¹ doctor
Your documentation should reflect YOUR SYNTHESIS and
INTERPRETATION of information stored in the EMR
Handout 5
Documentation Do’s & Don’t’s

DO

• Start from scratch

• Keep it simple and relevant

• Focus on YOUR questions and actions in the S and O sections

• Document and INTERPRET NEW studies only (not just report)

• Remember to click Refresh

• Make sure Note Date = Date of service

DO NOT

• include the HPI in daily progress notes

• pull in all labs and radiology

• repeat Assessment in Plan

• document what you didn’t do (history or physical)

• COPY FORWARD unless prepared to do significant editing each day

• copy and paste from someone else’s note

• Expect the EMR to do the work for you. “1 click and note’s done”

EMR ¹ doctor
Your documentation should reflect YOUR SYNTHESIS and
INTERPRETATION of information stored in the EMR
Handout 5
Documentation Do’s & Don’t’s

DO

• Start from scratch

• Keep it simple and relevant

• Focus on YOUR questions and actions in the S and O sections

• Document and INTERPRET NEW studies only (not just report)

• Remember to click Refresh

• Make sure Note Date = Date of service

DO NOT

• include the HPI in daily progress notes

• pull in all labs and radiology

• repeat Assessment in Plan

• document what you didn’t do (history or physical)

• COPY FORWARD unless prepared to do significant editing each day

• copy and paste from someone else’s note

• Expect the EMR to do the work for you. “1 click and note’s done”

EMR ¹ doctor
Your documentation should reflect YOUR SYNTHESIS and
INTERPRETATION of information stored in the EMR
Handout 5
Documentation Do’s & Don’t’s

DO

• Start from scratch

• Keep it simple and relevant

• Focus on YOUR questions and actions in the S and O sections

• Document and INTERPRET NEW studies only (not just report)

• Remember to click Refresh

• Make sure Note Date = Date of service

DO NOT

• include the HPI in daily progress notes

• pull in all labs and radiology

• repeat Assessment in Plan

• document what you didn’t do (history or physical)

• COPY FORWARD unless prepared to do significant editing each day

• copy and paste from someone else’s note

• Expect the EMR to do the work for you. “1 click and note’s done”

EMR ¹ doctor
Your documentation should reflect YOUR SYNTHESIS and
INTERPRETATION of information stored in the EMR