How to Write Clinical Patient Notes: The Basics

[thehusbandofstardomfamily]

Did this in RN school. Used this in Health Unit Coordinator.

What the patient describes--Subjective and what you observed--objective.
Assessment--a hypothesis about what you think is the issue/diagnosis/differential diagnosis
Plan--Management of care/consultation

[johnnewington]

From my experience in the UK, where they still use paper records, don’t forget to leave plenty of space at the end of your notes, so if you mess up, you can retrospectively update your notes to cover your tracks.
This appears an acceptable practice and accepted practice by doctors in the UK.
God bless all proficient and honest Doctors

[vannesa]

I feel so dumb. I just got a job and I’m not good at writing the chief complaint. I just got out of school and this is my first job. I need to work on this ASAP!! What do you recommend?

[maxmumbai]

There aren't many videos on this topic. If you could make a video on how to document a treatment plan accurately especially for Ob-Gyn patients, this would be really helpful. Thank you for your efforts, really appreciate it.

[shiuantzer]

Fabulous recording quality with practical information, thanks a lot!

[TheDufteLady]

I just discovered this channel. I hope he continues to post more of these videos🙏🏾😊

[thamsanqajanda]

Exactly what I've been looking for

[alyssawilson]

Thank you!! Great demonstration. Will definitely remember the SOAP acronym!

[Lizeth.]

I feel so silly here! Am a recently graduated Medical Assistant and I need this info 😆👍🏻

[fatal]

Well explained. It is very helpful. Thank you !

[carolineurban]

Was wondering if you only have 1 or 2 cateorgies within soap, how would that look like, or would you use different sub headings and what would those look like. Thanks alot.

[rupinderkaur]

Sir can you explain how to write a referral OPD slip to higher center

[cunggwok]

Is there any test when after hypothesis ?Do we need to anything when diagnosis ?After that, just straightly to give a plan to patient, and give the medication or something ?

[foryou]

Pharmacy note taking requires a credential (a printed 3x3 inch scannable barcode sticker with a 24 hour expiration period) to add a note into a pt's file which records 3 things:

1. The user's full name, title, and heading
2. Date/time
3. The respected note

Thankfully the majority of PAs are required to have hundreds up to thousands of patient care hours (as EMTs, pharmacy techs, nurses, ect.) which will hopefully serve to add our two cents to help our teams.

Dr., can you suggest it and have it become a possibility for clinical note taking in the future?

[victorjosemariangelogarcia]

Is it also same for how to make a patients protocol

[johnnewington]

From my experience, if your not sure, then leave a good space at the bottom of the page, so that if your wrong, then you can, if required, retrospectively add further comments.

[kingsleypepple]

excellent talk, focussed and precise

[deenacurls]

What if it is the spouse talking about signs of the patient. What do I do with that do i use that in the soap notes or leave it out. Noone talks about that

[JKLoria]

Great overview! Diagnosis specificity, acuity, type and etiology are of paramount importance for USA inpatient notes. Possibly probably Dx help for inpatient notes even though not coded for outpt.

[SensorySoundsASMR]

Question, if you are working under a physician as a tech, and the machine you are using on the patient is not printing out patient identifiers or timestamps which are critical in this type of test, and the doctor wants you to sign your name to this report knowing that the hard copy of the report is incomplete what would you do?