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SOAP Notes: The Down and Dirty on Squeaky Clean Documentation, by Jeremiah Fleenor
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The book measures: Width 5.85", Length 8.43"
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
- Sales Rank: #926758 in Books
- Brand: Brand: Shift 4 Publishing, LLC
- Published on: 2007-03-01
- Original language: English
- Number of items: 1
- Dimensions: 8.50" h x .19" w x 5.51" l, .25 pounds
- Binding: Paperback
- 80 pages
- Used Book in Good Condition
Most helpful customer reviews
8 of 9 people found the following review helpful.
So-So
By Billy J. Golden
I found some of the information helpful, however there was not really any additional information outside of what my texts as an FNP student offered, or quicker streamlined approach. I recommend other publications over this one for the student building a foundation in hx collection and documentation.
5 of 6 people found the following review helpful.
save your money
By C. Gal
its the most basic information i've ever seen regarding SOAP notes, can find more detail online. found the Jarvis pocket companion to be very useful writing notes
0 of 0 people found the following review helpful.
Out of date, often not relevant to current situations/real patient situations
By JR
Overall, I do not recommend this book for other students. I have listed below three primary problems I am having with this book:
1. The information presented in this book is often outdated and irrelevant to notes written in an electronic medical record, or it reflects something I am not physically able to do on the computer. The book is outdated; it does not even touch on the topic of how to document and write effective notes in an electronic medical record. The book only discusses hand-written notes and records. My notes are auto-populated with meds and lab values for the day, and the EMR keeps an updated med list for my patients.
2. The information is also overly-simplified for real patient situations. As example, when describing what a systems based CCU note would look like, this book does not take into account that patients in the CCU often have many, many medical problems. The book gives examples of how to write-up one problem under each system, but does not address how to write up, as example, the cardiovascular system assessment/plan for a patient with diastolic heart failure with acute volume overload in the setting of hypertension, a history of AAA, and a history of MI, s/p CABG.
3. Ultimately, the attendings and residents decide the "required" format for student notes. This "best" format changes dramatically from attending to resident to attending. The attendings and residents do not follow this book. To do well on my rotations, I need to follow the attendings, not the book. When I have written notes using this book as a guide, I have received more negative feedback on my notes than when I try to model my notes after the resident's or attendings' notes.
Initially, I bought this book as a required text for my second year of medical school. I did not find the book helpful during my preclinical years. Now, as I approach the end of third year, I continue to find this book difficult to use. Many students in my class did not purchase this book as required. They have not suffered for not having this book. My experience having this book has not changed my grade and has in no way made documentation easier during preclinical or clinical years. If this book were ever updated, I would recommend this book in a second. As is, I do not recommend this book to other students.
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