1. Back to the Basics
Writing Progress Notes at MSKCC
2. Daily Progress Notes
• Care should be taken to
make sure that
everything is accurate
and grammatically correct
• It should be clear for any medical professional to
read and understand what is going on with
the patient
3. S.O.A.P.
• Your notes should address the following:
- The patients clinical status: Are there any
changes in symptoms (nausea, vomiting, diarrhea,
fever, etc.)
- Physical Exam: What is today’s physical exam? Are
there any changes from yesterday’s exam (improving mucositis,
worsening erythema around central line, worsening edema, etc)
- Current/ pending lab and culture results
- New/ pending radiology results
-What is the current assessment and plan for this
patient
4. S.O.A.P. Note
• This is not a book – your
notes should be brief and
to the point.
• They shouldn’t take you
hours to write
• There should not be a lot
of copied/ pasted info
from the admit note (do
not include the ‘onc
history’ at all in your daily
notes)
5. S.O.A.P. Notes
• S = Subjective
• 0 = Objective
• A = Assessment
• P = Plan
7. S.O.A.P. Notes
• SUBJECTIVE – Typically says ‘interval history’
here at MSK
- Subjective observations = These are symptoms
verbally reported to you by the patient and/or
their parents, their spouse, etc
- Ex: I feel like crap, my back is still hurting, I
feel dizzy when I stand, my throat hurts, I feel
like a million bucks…
10. S.O.A.P. Notes
Always Inquire About the Chief Complaint
- If abdominal pain: find out if it’s better/
worse, pain scale, location, duration,
frequency
- Diarrhea: improving, worsening, blood
tinged, more formed, more loose, etc
11. S.O.A.P. Notes
• Subjective (Interval)
section May also
contain important
issues that happened
overnight as reported
by nursing/resident
on-call
12. S.O.A.P Note
• Sometimes if patient was very active in previous
24 hrs, the subjective (Interval) section can be
organized by problem in order to cover all the
information
– Ex:
• Resp Insufficiency: Patient continued to experience
dyspnea requiring increase in O2 flow overnight to 3L
NC. Repeat chest X-ray overnight with new positive
findings (results below).
• Hemorrhagic Cystitis: Patient continues to complain
of severe 10/10 lower abdominal pain and nursing
reports no improvement in color of urine (bright red).
• Heme: Patient with new petechiae noted at 2am,
with Plt 16 on midnight labs. Transfused 1 unit
platelets.
• ……..
13. • The Review
of Systems
should always
be updates
S.O.A.P. Note
16. S.O.A.P. Note
Sometimes a range is more important than a single
measure from a single time point.
• Ex: Pt with HTN, BPs range fro 113-156 (mostly in
140s)/56-94 (mostly in 80s)
19. S.O.A.P. Note
• Import needed
data by pressing
F6 and selecting
what you are
looking for from
the menu
20. S.O.A.P. Notes
Assessment
-A summary of the patient’s diagnosis,
clinical condition, and the objective
findings
-Sometimes the diagnosis has not yet been
established/ unclear so your assessment
could include several differential
diagnoses.
22. S.O.A.P. Note
For example:
Assessment: Diren is a 3 year old little boy with ERMS
of the pelvis on chemotherapy protocol XYZ admitted
for fever and neutropenia and management of
abdominal pain (Hospital day 2). Diren remains febrile
and neutropenic, and continues on Cefepime and
Amikacin. Blood cultures remain NGTD. Vital signs
remain stable. Abdominal pain well controlled with
PCA pump.
23. S.O.A.P. Noted
This is a section only
found in the BMT
Admission/Progress/Discha
rge Note, that helps
identify all of the patient
current active problems
that must be addressed in
the plan.
• Ex: Refractory AML,
chronic GVHD, Pulmonary
edema 2/2 fluid overload,
Hypertension, chronic pain…
24. S.O.A.P. Note
PLAN
- SELF EXPLANITORY: Should include the plan for the patient
- Should be well organized
- Style is a matter of preference: System based vs. problem based
- Should include:
- Laboratory tests to be drawn/ followed up
- Radiology studies to be performed/ followed up
- Meds to continue or discontinue/ dose to inc or decrease
- Consults to be called/ followed up
- Diet, IVF
- Disposition planning – Included when discharge to near
(home, hospice, long-term care facility, rehab facility…)
EVERY NOTE SHOULD END WITH DISPO!!
25. S.O.A.P. Note
It SHOULD NOT be a ‘shopping list’ of things to do
- Should be organized and focused
- Please separate Hematology and Oncology in
the system based approach plan while at MSK
26. S.O.A.P. Note
For example (system based approach):
1) ID:
- Continue Cefepime 750mg IV q8 hours and Amikacin 110mg IV
q 8 hrs
- Follow up Amikacin peak and trough to be performed before/
after the 4th dose
- Acetaminophen 225mg PO q 4hrs prn temp >38C
- Repeat cultures daily if febrile and/or change in hemodynamic
status
- Follow pending blood and viral cultures
- Continue Trimethoprim/SMX 80mg IV daily BID M/T/W for
PCP prophylaxis
- Continue Nystatin 10ml PO QID S/S for thrush
(ALL MEDICATIONS SHOULD BE INCLUDED IN
THEIR GENERIC FORM!)
27. S.O.A.P. Note
2) FEN/GI
- Continue neutropenic diet
- Routine I/Os
- BMP, Mg, Phosp to be performed in the morning
- Continue Ondansetron 2mg PO q 8 hrs prn nausea
- Continue Docusate 50mg PO daily and senna 1 tab
po qhs for prevention of constipation
28. S.O.A.P. Note
3) Heme: Pancytopenic
- Continue G-CSF 75mcg subq qhs
- Transfuse PRBC for hgb <8K and/or
plts <10k
- Continue to pre-medication with
Acetaminophen and Hydroxyzine
prior to transfusion
29. S.O.A.P. Note
4) Onc:
-On Protocol XYZ, Cylce X
-Next cyles of chemo/ dose of X due on Y
- Cyclophosphamide to be started tonight. Will
continue to monitor for signs of SIADH (decreased
UO, decreasing serum NA, increasing spec. grav…)
- Will repeat BMP 4 hours after infusion
- Will have all urines dipped for heme (monitor for
hemorrhagic cystitis) …
30. S.O.A.P. Note
5) Pain
- Continue
Morphine PCA
0.3/0.2/10
- Continue to
monitor status of
abdominal pain
31. S.O.A.P. Note
• Only check off
resident
complete once
you are
confident that
the note is done
32. S.O.A.P. Note
• Once note is done,
send to attending by
selecting “Authored
by Other” and
choosing your
attending from the
list
33. S.O.A.P. Note
Don’t be sloppy – you’ll only
be embarrassed
Keep the easy stuff correct:
- POD #/HD#
- Patient’s diagnosis
34. S.O.A.P. Note
• Avoid non-hospital
approved abbreviations
• This is a legal document
so think twice about
what you write (be
conservative)
35. A Note about Discharge
Notes
• Fill out only
what is relevant
to the current
admission,
otherwise you
can write N/A.
36. A Note about Discharge
Notes
• The hospital course
should be the started
course from H-drive
word document, and
should include only the
relevant information
that took place during
hospitalization, by
problem/system
– Avoid needless minutia such
as “fluids were weaned to
2/3M on 5/4 then 1/2M on
5/5 and off by 5/6”. Ok to
just say fluids weaned as PO
improved.
37. • An active medication
list should be included
in the d/c summary
• In the MSC section,
record the I-STOP
Ref# I will provide
you for your patient if
controlled substance
is being prescribed
for home
A Note about Discharge
Notes
38. A Note about Discharge
Notes
Since the discharge note will also serve as your
daily progress note, make sure the ROS, Vitals and
exam are all up to date for the day of discharge.
39. • Include all the
relevant Radiology
Studies, Pathology
reports, Flow
Cytometry
results…
• Can paste by doing
F6, but edit to
include only the
relevant impression
from report
A Note about Discharge
Notes
40. • The impression and Plan in the
discharge summary are the big
picture ones that demonstrate
what is the longer term
expectation and prognosis for
patient
– Ex: 7 yo female with pre-B ALL, now s/p
completion of induction and consolidation
therapy on protocol XYZ. Treatment c/b
typhlitis resulting in SB resection and
ileostomy. Patient now s/p takedown of
ileostomy and parenteral nutrition,
tolerating regular diet. Patient with 0%
MDR and negative LP on 8/17/2014.
Patient planned to return to Ohio, to
start maintenance treatment and return
to MSK for follow-up in 3 months.
A Note about Discharge
Notes
41. • The plan in the discharge summary
should be the go-home plan by
problem/system, and include all home
medications and follow-up
appointment.
A Note about Discharge
Notes
42. • Always imagine yourself as the
receiver of the discharge note for
your patient in clinic. What would
you, as the clinical taking over the
patient’s care want to/need to/not
want to know.
A Note about Discharge
Notes
