How to Write Medical SOAP Notes | Expert Physio Explains Top Tips!

so i was once told by a lawyer when writing medical notes you need at least three specific patient identifiable markers on each page such as their name their date of birth or their hospital number for more tips including how to make sure you keep up with your notes during the day keep watching hey guys khalid here welcome back to clinical physio so writing medical notes is one of those things that therapists naturally struggle with in the early parts of their career and as a physiotherapist myself i commonly see this in student and junior physios so here are my top five tips for helping you with your medical note writing so top tip number one always write down the date and the time on your medical notes many believe that just the date is important but the time is absolutely pivotal especially in an inpatient environment on the wards where there are so many different professionals attending to that patient and the patient is having so many different interventions going on and you want to be in the right place in that chronological order so for example did you attend and mobilize the patient before or after they had their x-ray confirming that there was no fracture writing down the time in your notes ensures you're on the right side of that top tip number two get used to writing your notes in shorthand format use things like arrows the up arrow for increase the down arrow for decrease the forwards arrow for things like therefore or this leads to the greater and less than signs or in particular the small no which is the degree sign and you might use this for writing things like no significant problems but not only writing these things in your notes why not practice doing that at different times of your normal day maybe you're writing a quick message to someone in the house write it on a piece of paper in shorthand hey maybe even a text message if you want the key thing is getting used to doing it so when it comes to doing your notes it's natural for you top tip number three which abbreviations to use now here in the uk each nhs trust will have an individual set of approved abbreviations for you to use but here are a few common ones that are going to be in 99 of those approved lists so we might be thinking of things like pmh past medical history hpc history of presenting condition ax which stands for assessment rx which stands for treatment mx which stands for management sx which stands for symptoms hx which stands for history or dh which stands for drug history these are a couple of common examples you'll see time and time again now of course there are loads of abbreviations that we use all the time and we've gone through loads of these on our specific writing soap notes on demand tutorial and you can find a link for that in the description below if you want it's one of our most popular tutorials so tips four and five i thought i'd focus a little bit more on the logistics the organization or the systemization of how and when to write your notes during the day so top tip number four write down as much of your notes down as you can whilst you are with the patient now this is going to be most relevant to people working in a musculoskeletal environment or a community setting for example because that's when the patient is going to be telling you their subjective assessment whilst you're in front of them or that you're going to be completing specific tests whilst with the patient in the cubicle and you can write things down as you go that's a huge tip of mind write these things down as they're happening now whilst of course you want to show your patient that you're engaged in the session and therefore you don't want to be staring down at your notes all the time i would say that writing your notes down when you're with the patient saves you so much time later on and also guarantees that they're as accurate as possible so i would say that i complete all of my subjective assessment and at least 75 of my objective assessment notes whilst i'm with the patient there and then and i still think you can gain plenty of rapport by taking the time to explain things during your advice and take the time to practice exercises properly which is going to help you build that report whilst also managing your notes properly now imagine that didn't happen imagine you have to write the full subjective and objective assessment for your patient after they've left think of how much you will have forgotten think how much more time it's going to take you thinking about did they do this did they do that it makes me nervous just thinking about it and finally top tip number five the clearest one never try and write three to four sets of notes all at once all at the end especially if you haven't been writing down your subjective and objective as you go with each patient so just for a second quick game for you without confirming with someone else or without checking your phone try recalling to me all of the things that you have done in the last three to four hours every action you took everything you ate everything you drank every person you spoke to either in person or on your phone every song you listen to every video you watched it's quite hard isn't it and that's all the things happening to you personally now imagine having to recall everything that has been said to you or every test that you've done for three to four people who you've just met for the first time which patient said that they liked horse riding which patient said they had trouble sleeping and what position was it in how many degrees of flexion did that person have at their knee it's really hard in fact i'd say it was almost impossible don't do it especially if you're not the kind of person who wants to write down the subjective and objective assessment as you go sure if you have to leave the analysis and the plan to the very end that's fine you're subjective and objective if you've been writing it as you go along will help guide you through those sections but to try and come up with all of that information all in one go it's going to take so much time you're definitely going to get it wrong and it's going to give you a lot of headaches so don't do it so guys for even more tips as we said we have our on-demand tutorial on writing soap notes you can either access this as an individual order or as part of our clinical physio premium membership details of both are in the link below but otherwise thank you so much for watching please support us by smashing that like button and subscribing to the channel or follow us on social media like our instagram clinical physio thank you so much for watching i'm khalid see you soon here on clinical physio

Channel: Clinical Physio

Views: 10,709

Keywords: physiotherapy, physiotherapist, sports therapist, doctor, medicine, anatomy, youtube, youtube teaching, youtube physiotherapy, how to, musculoskeletal, assessment, physio, physio student, student physio, physical therapy, physical therapist, youtube physio

Id: GEporeEsaZA

Length: 6min 18sec (378 seconds)

Published: Tue Jul 12 2022