However, as you rotate through the wards, you realize that each service has its own way of writing a patient note. Knowing the particular format of a note by service is helpful. For example, for inputs/outputs on neonatology, you want to mention the volume per gram weight of the baby, but this measurement is nonsensical on a general surgery service. Therefore, this post aims to describe how to write a SOAP note for a surgical patient. Future posts will cover notes for patients on core services, such as medicine, pediatrics, and OB/GYN.
As before, the basic format for a note is the SOAP note. SOAP stands for:
Subjective: any information you receive from the patient (history of present illness, past medical history, etc)
Objective: any data, whether in the form of a physical finding during your exam, or lab results
Assessment: diagnoses derived from the history and objective data
Plan: what you intend to do about the diagnoses from your assessment
For surgeons though, rounding is brief and sometimes treated as a loss of time from the OR. An attending surgeon can function just fine with that attitude, but a medical student should not share it in order to excel on the service. The ideal student on surgery should be able to document the patient's complaints and exam findings succinctly, assess them, make a plan for treatment of any issues found, and anticipate and prevent other common problems.
The surgery note starts like any other note. Date and time the note, then write down your position and title of the document, such as "MS3 Purple Surgery Progress Note". Next, note the postoperative day, or POD. If the patient just returned from surgery, denote that day as "POD #0". If the patient was previously started on antibiotics, it is also helpful to denote what day of antibiotics they are on.
For the SUBJECTIVE portion of the note, you want to include any complaints the patient might have. If the patient is recovering normally, be sure to ask about return of regular body functions, such as voiding, passing flatus (gas), tolerating PO (oral food), and ambulation (walking) and mention these briefly in your note.
For any symptom like a cough or rash, use the OLDCHARTS mnemonic from "How To Write a SOAP Note" to further describe the complaint. Using a book like Surgical Recall, make yourself aware of the major problems in a post-operative patient (typically, the patients you would be writing notes on). In particular, be aware of fevers in the post-op patient, a very common and potentially very dangerous finding. A simple mnemonic to keep in mind is the 5 Ws for causes of postoperative fever:
WIND - stands for atelectasis, the most common cause of fever on POD #1
WATER - stands for UTI, the most common cause of fever on POD #3
WOUND - stands for wound infection, the most common cause of fever on POD #5
WALK - stands for DVT, the most common cause of fever on POD #7
WEIRD - stands for drug-induced fever or abscess, the most common cause of fever on POD #9 and beyond
For the OBJECTIVE portion, the note should include the vital signs, I/Os including from drains, and physical exam findings. The vital signs should note the maximum temperature and at what time it occurred. If above 38 deg C or 101 deg F, note what was done to remedy the fever (if anything). For the I/Os, note the rate of IVF administration and the fluid being administered. Also note the location, amount drained, and quality (serosanguinous, bloody, purulent, etc) of any Jackson-Pratt or JP drains here. The physical exam can be brief, but should include the pulmonary, cardiovascular, abdominal, wound, and extremity exams. A normal exam may read:
GEN - A&O x 3 (alert and oriented to person, place, time)
PULM - CTAB, no C/W/R (clear to auscultation bilaterally, no crackles, wheezes, or rhonchi)
CV - RRR, no M/R/G, 2+ pulses (regular rate and rhythm, no murmurs, rubs, or gallops, good pulses)
ABD - +BS, S/NT/ND (positive bowel sounds, soft, nontender, nondistended)
WOUND - c/d/i (clean, dry, intact)
EXT - no c/c/e (no clubbing, cyanosis, or edema)
For the ASSESSMENT portion, the note should give a one sentence summary of the patient and why they are in the hospital. For example, "35yo female s/p lap chole stable on POD#2." For patients with complications, consider adding a clause or another sentence describing the reason for an extended postoperative stay. For a patient with fever, you might say, "Patient developed fever on POD#5, subsequently found to have bilat DVT by duplex US."
For the PLAN portion, the note should address any issues raised in the subjective, objective, or assessment sections. Address each issue specifically. If unsure, refer to a book like Lawrence's Essentials of General Surgery for management. For every patient, include a plan for their fluids/diet, pain control, prophylaxis, and disposition (how are they getting home). For prophylaxis, the major issues to consider are DVT prevention and peptic ulcer prevention. For deep vein thrombosis, thromboembolic deterrent (TED) hose and/or sequential compression devices (SCDs) should suffice. For ulcers, try any proton pump inhibitor (PPI) such as pantoprazole (aka Protonix).
If you follow this basic structure, you should do just fine as far as SOAP note writing on surgery goes. The key to a surgery SOAP note is simply this: be concise but precise. Or, another way to remember it, is: Just the facts, med student. Just the facts. Good luck!