Writing a good progress note

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Hey guys, Doctor Dasi here from osmosis and I wanted to talk to you guys uh this week about how to write a really good progress note uh or clinical note and I brought with me a little prop.
So this is just to remind you uh what we're talking about today. And if you've written a note before, you know why I'm holding this up, let's see if I can.
There, it is so ap subjective, objective assessment and plan, right? Soap or soap notes are, are what we call them sometimes.
And it's just a short hand from one, remember, kind of what uh what we should include in the note. The subjective is what a patient tells you.
Objective is kind of what you determine by yourself through physical exam or labs or imaging assessment is kind of your thought process.
What do you think is going on and, and explaining that fully? And a plan is just that it's like, what are you gonna do next?
So this is a soap note format. It's pretty universal.
And so this is what we wanna talk about today. What are my top three tips for writing a good note and this is kind of over the, over the many years I've kind of started really thinking about it and, and come up with it, let me dive into what I like to do.
So my top three tips, top tip number one, write a story. Keep in mind when a patient comes to you and they have a problem, whatever problem they might have, they, they'll say, oh, you know, my hip hurt and then I was walking and it hurt more.
And then now I feel like, you know, maybe it's getting really, really bad and then you ask them, oh, what, what, what do you think caused it?
Oh, you know, I think it may have been because I went to the gym, you know, and I was exercising. So you're kind of putting together a story and sometimes, you know, it's hard as a patient to kind of put the story in order chronic chronological order.
They're kind of just telling you bits of the story. It's your job in the history and physical, which is also kind of the subjective and, and objective part to lay out the story and say, ok, look, uh we, we understand that you had kind of hip pain, but let's start with kind of going to the gym and then the hip pain started maybe three days later.
And then on, on physical exam or the assessment part, I noticed that it's hard for you to move your hip in a certain direction.
So maybe that kind of gives you a clue as to what's going on. So that's telling a good story.
You know, for example, the same story, if you're not telling a good story, it would be like, oh, a person who had hip pain.
And then a month ago they had a runny nose and it lasted three days. And, uh, and then they recently traveled to New Zealand and they came back and they, they eat a lot of kind of fatty foods.
It's kind of all over the place, right? That's not a good story.
I think if you're listening to that story like, well, what's going on? Where, where's the, where's the story arc?
What's, what's even happening? Like if you're watching ATV show like that, you probably click away, right?
So tell a good story, write a good story, make it, make sense, logic because what it does is it kind of feeds into the next parts of the, of the history you want to say?
Ok, so tell me more about the gym. What were you exercising?
Were you exercising your arms, your legs? So write out when you're doing your history and physical and you're writing down your soap note in your subjective and objective.
You want it to flow very naturally. It makes sense.
So it kind of builds up to a crescendo, which is your assessment. So tip number two, remember that when you're doing the assessment, a diagnosis is a label.
So it's very, very important once you write down a diagnosis in your chart or, you know, you write in your assessment, you know, I think this patient has, you know, let's say a depression or chronic fatigue, that label is gonna stick with that person.
They're gonna go around, that patient chart is gonna follow them. And so remember that that's not an easy label to kind of shake off.
I'll give you a quick story. I had a patient who is vitamin b12 deficient.
And in the chart, it, it said things like, you know, patient is depressed patients kind of feeling headaches and because it said those things every time the patient said, oh, I feel really fatigued or tired people just said, oh, well, you know, in the chart, it says diagnosis, depression.
So that's probably what it is and they didn't really think or given any kind of value. And so when you write your assessments or write your diagnoses, you know, every other doctor is gonna see that and they're gonna kinda think in the same way.
So you're, you're really cheating that patient out of giving them a fair shot at getting the real diagnosis. So when you write your assessment, think about all sorts of things like what's the worst case scenario, what is the full differential of, of what could be going on?
And if you're not sure about something, you can add that in your assessment and say, look, uh this seems possibly to be depression.
But other things that we should really consider would be, you know, causes like uh hypothyroidism or vitamin B12 deficiency.
See, so just writing that out and even if you don't have the answer, just saying like there could be other causes or something about this doesn't make sense.
It's really, really important. So just make sure you put your full assessment in there so you don't cheat someone out of getting the right diagnosis, maybe down the road.
All right, next the third tip, then make a specific plan, not just like plan to lose weight, but maybe reduce soda from three times a week to one time a week, uh, or start drinking a healthy smoothie for breakfast and maybe even look up a recipe with the patient.
So when you're doing the plan, I want you to be very specific. So say things like, hey, uh this patient has agreed to kind of going down on their cigarettes from 20 cigarettes to 10 cigarettes a week, you know, very, very specific and, and I'll tell you why.
When I started writing soap notes, I used to think, oh, you know what a soap note is a way to communicate with other doctors and nurses and pharmacists.
Uh, my thoughts, that's what I thought and that's true. But then about a year or two later I started getting uh meetings with people in the hospital that said, hey, we want you to write your soap note so that it actually makes sense for insurance companies uh for the E Mr.
And so we wanted to check all these boxes and I thought, oh, ok. So I guess the soap note is a legal document, a business document so that we have to uh communicate with insurance companies what we're doing.
So we get paid. So I thought ok, that's what, that's what a soap note is for.
And then as I kind of went on, I realized actually it's not just that it it is that but it's also something more, it's also a contract between you and your patient.
It's, it's a trust you're saying to them. And this is what I do now with my soap notes, I read my soap note back to my patient.
You know, at the end, I'll say kind of like just quickly highlighting the things that I think are important. And then when I start a new visit, like let's say I see him in a few months, I read it again and say, hey, last time, what we talked about was this, this and this is that your understanding and they say, yeah, that that's about right.
And they can kind of fill in the gaps too. So I really want you to think about your, your progress notes as a contract between you and your patient.
And the goal of a good soap note is to a get the information right? You know, again, writing a good story tip.
Number one, it's, it's number two, make sure that the that the assessment is truly thought through uh because the assessment or diagnosis is a label.
So make sure you think about that. And number three, make sure that when you're writing a plan, it's very specific.
So again, number one, write a story. Number two, remember that your diagnosis is a label and number three, make sure that you write a very specific plan.
Uh I'll see you again later. Bye-bye.
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