How to Write Clinical Patient Notes: The Basics

This is a quick video from the University of Calgary that covers the basics in how to write clinical patient notes. It covers some key principles that protect patient safety and ensure you are effectively communicating with other health care professionals. For more great clinical education materials, go to sharcfm.ca, the Shared Canadian Curriculum in Family Medicine!

[@thehusbandofstardomfamily6152]

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

[@dkcalgary]

Yup! Love it!

[@shiuantzer]

Fabulous recording quality with practical information, thanks a lot!

[@dkcalgary]

It was professionally recorded by our av team here at UCalgary! Thanks for the feedback!

[@thamsanqajanda7678]

Exactly what I've been looking for

[@dkcalgary]

Dear Thamsanqa, thanks for the feedback!

[@alyssabrown6214]

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

[@dkcalgary]

Great! I learned it on my first day in a clinical environment as a first year medical student working with Dr Dan Malone in Placentia, NL, and am happy to pass it on!

[@helenghandchi8280]

Thanks for all the valuable videos.

[@dkcalgary]

you're welcome!

[@SurajKumar-oo8vr]

Very nicely explained. Thankyou

[@fatal2340]

Well explained. It is very helpful. Thank you !

[@TheDufteLady]

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

[@dkcalgary]

Hi, once things settle down clinically, I will. Sadly, most governments have abandoned all covid precautions, and covid and post-covid continues to grow.

[@kingsleypepple862]

excellent talk, focussed and precise

[@dkcalgary]

thanks for the feedback!

[@moshfiqurchowdhury3698]

Thanks sir for wonderful demonstration.

[@dkcalgary]

You're welcome!

[@boscomoons7742]

Thanks a million; the video is precisely informative

[@maxmumbai1234]

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.

[@dkcalgary]

I'll add that to my list. (It won't be O/G specific but will use an OG example .) it will take some time as I'm still swamped with clinical work related to covid.

[@mizwarmalek5487]

good information to my research .

[@RestaurantRemix]

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.

[@dkcalgary]

There are lots of variations by medicare / government/ insurance / etc for sure.

[@jeanniebeneanie3752]

Much appreciated, thanks 😊

[@abigaillynn3664]

I'm 12 and I love this account!

[@dkcalgary]

I'm delighted to hear!

[@dramina2326]

Fantastic!

[@dkcalgary]

you're welcome!

[@20vannesa]

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?

[@dkcalgary]

I think this video can help you? In general, chief complaint/concern should be brief but then backed up with detail.

[@trentcalson105]

@@dkcalgary My supervisor asked for a hospital release note before getting back to your and I'm happy I found Cyber Credible through the comments below. They're helping people with legit doctors note

[@trentcalson105]

Allow a professional handle your doctor's note if you can't get one from your doctor or hospital

[@brandonnotsowise2640]

I suck at the hpi’s. Having a lot of trouble with this.

[@pieevlogs]

😅

[@Georggia1299]

So helpful thanks!

[@ayubdamra562]

wattsgoodforyou fish dgk gf ddgmmd

[@veerukabaka6470]

Great work Dr, our Practice at Illovo follows you vigorously and gas for years

[@dkcalgary]

Great! Take care!

[@Ashley832]

Thank you. 🥺💜

[@dkcalgary]

Ur welcome!

[@medicnotes]

❤❤ hi, great channel you have here! striving my best to create good revision videos for medical students as well 😄

[@DrAdnan]

helpful thanks

[@dkcalgary]

Great! You're welcome

[@HM-cs9vw]

one day in the future I would love to meet you and thank you doctor for your efforts!

[@dkcalgary]

Dear HM, that is a gracious thing to say! I would love to meet you too. I'm at the University of Calgary - look me up if you're ever in town.

[@jurgentmeythlaer1058]

thank you

[@dkcalgary]

you're welcome!

[@Lizeth756]

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

[@ASHAKUMARI-ig1fv]

Thank you so much

[@ikramgh7562]

thank you ! :)

[@dkcalgary]

You're welcome!

[@carolineurban7571]

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.

[@Travis.L]

thanks Doc!

[@dkcalgary]

Ur welcome!

[@sujonroy8487]

Thank you sir

[@dkcalgary]

You're welcome! dk

[@dragondanceable]

TK. this is very useful for a clinician

[@nelsonproches6526]

Good

[@HanMinThu-es9od]

Thank you

[@gimmygeorge559]

Nalla eruku. Useful

[@kalungirenah650]

Perfect thanks dia dia

[@DilipSingh-ve9ly]

Great sir

[@joypauline3236]

I was really having a hard time getting my patient note last week😓😓 but I’m all good and that’s #Cybercredible# work 👍

[@ticocampos8384]

Great video. How many hours do physicians spend with paper work per day? Do you do this notes in the end of your day or while talk to pacients? Is faster to dictate? Do you spend more time with pacients or doing paperwork? Thanks🙏

[@chazzyschannel]

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?

[@dkcalgary]

great question. Happens from time to time. Take the extra time to put the full patient's name, date of birth, and their unique identifier for your jurisdiction (in Canada, it would be their provincial health card number). Sure it's a pain, but I do this even now, anytime I'm doing anything official for a patient. Good example: I had a frail patient in the community and was doing lots of housecalls. I had to make small adjustments to her medications. Every so often, I would do up a formal new medication profile in her home, on paper, so that if she got really ill, the paramedics would have an up to date list. So, each time I wrote out a revised list, I added her name, date of birth, and health card number on the top. Takes time, but it's safe patient care.

[@TheNaturalRunway]

🙏🏻

[@dkcalgary]

You're welcome!

[@MrBhart2408]

Thank God for Epic!

[@melodysagayap6044]

Amazing

[@cunggwok148]

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 ?

[@dkcalgary]

This only teaches how to assess someone's acuity. It doesn't give you the diagnosis. So if someone had reduced acuity, then you would need to examine and try to figure out why, possibly including a optometrist or ophthalmologist.

[@411foryou]

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?

[@dkcalgary]

Interesting. I'm not in the inpatient world much anymore (although, I did recently do a bunch of inpatient visits on a complex patient of mine and, sure enough, it was back to paper and printing my name, signing my name, and printing my pager number!). In my primary care world, everyone is electronically authenticated, so the EMR automatically knows who wrote what. But that's a great idea for the hospital world. When I was in training, I ended up getting a little stamp made up to save time, so I would sign my name and then quickly stamp just under it - it had my name and pager printed.

[@mehditila7424]

❤💛💙

[@victorjosemariangelogarcia6882]

Is it also same for how to make a patients protocol

[@dkcalgary]

Hmm. I'm not sure what you mean by "patient's protocol". If this is documenting the plan (medications, investigations, etc.), then all that stuff would go under P for plan, perhaps in a bulleted list.

[@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

[@dkcalgary]

Great question! I put that in subjective clearly marked like "husband states pt has been quite forgetful". The reason is that it's part of the story. It's similar to if a patient was seen the day before by another doc, I put the story to this moment in time in subjective, and what I find or see in real time goes in objective. Sometimes people will split labs or investigations into its own category after Objective.

[@abderrahimamazire4340]

God bless you

[@dkcalgary]

Thanks very much! Take care!

[@chadlineage]

where i come from we add I and E , making the abbreviation spelled as S O A P I E. I -for implementation and E- for evaluation... but i find this simple and straight forward thanks... watching 2020

[@dkcalgary]

I remember hearing about the I and E once long ago. I put all implementation in the plan, and any plan to evaluate (such as checking bp readings) also in the plan like "follow up in 2 wks" or "pt to gather home bp measurements x 10 days and then have virtual visit".

[@chadlineage]

@@dkcalgary more of like patient management based on what was seen from the time S/O was taken down along with patient health history on which where appropriate diagnosis is taken from, and evaluating thru follow up check up thru lab results etc Yes doc nice refresher cheers!

[@poojagandhi4207]

❤❤❤❤

[@nicoletteburton5697]

❤❤👍

[@rupinderkaur7386]

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

[@dkcalgary]

Hi! I made a video for that too, right here: kzbin.info/www/bejne/rGKqknWMrdqGoNU

[@johnnewington6635]

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.

[@technoshindo]

Shoutout from Section G - Gpcom lel

[@lakshmitriveni3436]

Tq so much. Is there any app for patient case presentation

[@tonikatonika3979]

How to put daily notes for admitted patient?

[@dkcalgary]

@@tonikatonika3979 NOt sure about an app, but I created a video on that right here: kzbin.info/www/bejne/g5baY6qwpdqbitU

[@youngbabilon8280]

nice

[@dkcalgary]

Thanks!

[@abdallahabunamous3537]

beautiful

[@dkcalgary]

Thanks!

[@tonikatonika3979]

How to put daily notes for admitted patient? Is that same ?

[@dkcalgary]

In general, it's the same. But it's always good to identify at the top which day in hospital, or days post-op, etc. If it's a really complex patient, you would write notes by system, as there would be too many separate issues to keep track of.

[@OfficialRyanx]

And ensure that all of this is done within the allocated ten min slot that you have with your patient.

[@AP-wt4fi]

I'm a Medical Assistant student, and in my class, we are learning how to take patient notes but I'm having a tough time with it I'm not good at writing. Ugh, I can tell I'm gonna have trouble once I'm working in the field.

[@dkcalgary]

Hang in there. When in doubt, just use quotations from the patien's own words. In fact, that's often the best way to capture things. I find the linger I've been a doc (26.5 years now!?!) the more I record their exact words. It helps with painting the picture. Best of luck, David

[@AP-wt4fi]

@@dkcalgary thank you very much.

[@alainaharmon2575]

They're on IG

[@dkcalgary]

Hi Alaina, thanks. When you say "they're on IG" do you mean someone is distributing my video(s) on IG? If so, can you pls tell me the insta account? Thanks! :)

[@flora20]

I’m a patient and unfortunately some doctors do not make accurate notes I’ve even had some letters where I’ve been called him/he and the wrong name! It’s really upsetting I hope more doctors watch this and improve their note taking. Getting inaccurate reports of what happened can be unnecessarily upsetting.

[@dkcalgary]

I'm a patient too, and I agree: careful documentation is really important. Take care

[@flora20]

@@dkcalgary it’s even more crucial when you see a few different specialities and sometimes one doctor forgets to note something and then the other doesn’t know about it. I wish more doctors were like you- thanks so much for this video it is appreciated

[@dkcalgary]

Flora 20, yes this is a serious issue. Then what happens is the stuff written down is often viewed as the truth, even when a patient points out errors. I have encountered this myself as a patient. Happily, a senior nurse stepped in saying, "you're not a prisoner, the wrong meds have been sent up, you need sleep. Just take the medications you've been taking for years; you know your body best." It was great to be part of my health care team and listened to. I often think: what about the patients who don't know the questions to ask or things to check?

[@julescastaneros545]

how to create a PRIME?

[@thesuccesscoach5474]

Documenting services :)

[@gumgumdookuin7963]

So this is how you write an SCP article. :P

[@dkcalgary]

Hi, sorry, I'm not sure what you mean.

[@gumgumdookuin7963]

@@dkcalgary Sorry. Lol. It's a website where horror like stories go about. They sometimes wish of you to write in a clinical fashion. Hints what I said.

[@renulokhande6113]

Pls translate hindi

[@samad3251]

WHY???

[@dkcalgary]

Hi, as a family doc, I do have lots of skills, but my Hindi is really, really weak. I suggest you turn on the closed captioning, and somehow cut and paste it into Google Translate. Take care!

[@mirlenefrancisque3642]

7

[@jerviekeith2736]

The link sucks lmaaoooo

[@dkcalgary]

Which link?

[@Harlem55]

Heres the thing: courts and juries dont like medical terminology. Aim to write in a way that avoids unecessary technical terminology.

[@sknaseernaseer6911]

Urdu me

[@patrickx2420]

The title was how not why... Just get to the how

[@abderrahimamazire4340]

Thank you

[@supashyarc]

Thank you sir

[@dkcalgary]

You're welcome!

[@gloryjay2025]

They're on IG

[@dkcalgary]

Pls send me the link if you can. Thanks!

[@edis9493]

Thank you

[@dkcalgary]

You're welcome!

[@ceciliaziba8541]

Thank you

[@dkcalgary]

Ur welcome!

[@trentcalson105]

They're on IG

[@dkcalgary]

Pls send me the link if you can. Thanks!