This document provides guidance on writing effective SOAP notes for post-partum patients. It explains that SOAP notes are an important way for healthcare providers to communicate about a patient's condition and care over time. The document reviews the components of the SOAP note format, including the subjective, objective, assessment, and plan sections. It emphasizes that SOAP notes should concisely document the key relevant exam findings and status of the post-partum patient at a moment in time to inform future care.

1. ZEN AND THE ART OF SOAP
NOTE WRITING
A presentation on why SOAP notes matter, and
how yours can be the best
By: Marcy Rosen
MD and avid SOAP note reader

2. In this presentation you should learn:
¨ Why we write notes on patients
¨ The 4 points of a SOAP Note
¨ Information most relevant to post-partum SOAP
notes

3. WHY WRITE A SOAP NOTE?

5. SOAP NOTES ARE NOT FOR YOU!

6. S.O.A.P. Stands For…
• Subjective
• Objective
• Assessment
• Plan

7. Subjective/ Objective

8. Subjective: Just the facts

9. Subjective: Post-Partum Patients

10. Objective: Post Partum Patients
• Constitutional Status
• Lung Sounds
• Cardiac rate and rhythm
• Breasts: Engorgement?
• Abdominal Exam:
• Pain
• Bowel Sounds
• Fundal Size
• Wound Status
• Visual Vaginal Exam: Lochia
• Extremities: Swelling? Reflexes

11. Assessment
¨ Your assessment should explain in one sentence why
the patient is there and how she is doing.

12. Assessment: Post Partum Patients
¨ Examples:
¨ 31 y/o G3P3 post-operative day 1 after primary c-section
for fetal intolerance to labor
¨ 28 y/o G1 P1, post partum day 1 after NSVD
¨ 32 y/o G3 P2012, post partum day one after SVD, severe
pre-eclampsia
¨ 19 y/o G1P1 day 3 s/p NSVD with chorioamnionitis, now
resolved

13. Plan
¨ 1. Link the subjective and objective to the
assessment
¨ 2. Address the next
step in the patient’s
clinical course

14. Important Points:
¨ Your note conveys the snapshot of a patient at a
moment in time
¨ It is important to limit your note to pertinent
information
¨ If you include something outside of normal limits in
your subjective or objective, it needs to be
addressed in the assessment and/or plan

15. Most importantly!!!!
¨ Your note is written for the next person reading it!

16. Most importantly!!!!
Write your note as if
the next person
reading it has NO IDEA
about the patient. Your
note should convey
everything they need
to know.

17. Plus the added bonus:

18. Now: YOU are the expert!
You can do it!