Soap Notes: The Down and Dirty on Squeaky Clean Documentation - Paperback

by Jeremiah Fleenor (Author)

Do you feel like there's more to the SOAP note than the S, O, A and P? Well you're right. This book will show you just how much more there is and what you need to do to write great notes. This book is like a double shot of espresso: concentrated, direct, with only the essentials. After reading this book you will be so excited for your clerkships that you'll have to try not to honor! This Book Covers: - the components of the SOAP note - important little things they don't tell you in medical school - when to use a SOAP note vs. an H&P - abbreviations - handwriting and spelling - dealing with errors - the summary statement (the most important part of the note) - avoiding lawsuits - differences between the SOAP note for the primary team and the consultant's team - properly consulting a specialist - where to get the essential information quickly (time saving techniques for the wards) - how to use your SOAP note for oral presentations - 3 structuring choices for the Assessment and Plan - differences between the clinic, ward and ICU notes Bonus Features: - skeleton notes - reference guide - tips from inside the hospital