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 beganL - 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 - RadiationT - Temporal: is there any pattern to the pain, such as always after mealsS - 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!