YT YouTube2Text

YouTube2Text → Transcripts → SOAP Notes and Presentations

SOAP Notes and Presentations — Transcript

by Strong Medicine · 2,759 words · 448 segments · language en · Watch on YouTube

Open in transcriber Summarize with AI Download SRT/VTT

Full transcript

0:01hello I'm Eric strong from strong
0:02medicine and today I'll be continuing
0:05this series on medical presentations and
0:07written notes I've already covered the
0:10medical hmp including two example
0:13presentations this video will describe
0:15the content and format of the so-called
0:18soap note and soap
0:20presentation notably although soap is a
0:23different and shorter format than the
0:25hmp many of the same general principles
0:28apply so if you're un familiar with hmps
0:31you may want to start there first and
0:34come back to this
0:36afterwards now one is the purpose of the
0:39soap note and presentation in extreme
0:42brief the soap is a daily update
0:45provided for a hospitalized patient it
0:48communicates to other members of the
0:49broader Healthcare team what's changed
0:52about the patient in the preceding 24
0:54hours and how your plan has changed on
0:57account of that the soap for format is
1:00used primarily by the so-called primary
1:03teams in the hospital that is the one
1:05team who coordinates care for a given
1:08patient however some Consulting teams
1:10will also employ a soap-like format for
1:13their documentation and bedside
1:15presentations as
1:17well while it may not be apparent in
1:19most hospitals or on most inpatient
1:22Services soap is only one possible
1:25format of the daily update albeit by far
1:28the most common one
1:30the more general term for the written
1:32form of the daily update is a progress
1:34note so in short all soap notes are
1:37progress notes but not all progress
1:40notes are soap notes alternatives to
1:43soap include these system based notes
1:45and presentations common in icus which
1:47are similar to soap except the plan is
1:49organized by organ system rather than by
1:52individual problem whether or not that
1:54format is actually better in the ICU
1:56environment is debatable there's also a
2:00more recently described alternative to
2:01soap called the EAP notes and
2:04presentation in my opinion EAP is the
2:07best format for physician and AP teams
2:10despite it being the least commonly used
2:13I'll be discussing it in an upcoming
2:15video in this series and last there's
2:18something called the Apso or abson notes
2:21which is just a variation on soap in
2:23which the order of the SN and the are
2:26switched but everything else is
2:28otherwise unchanged
2:30the rest of this video will focus solely
2:33on soap notes and soap
2:36presentations soap is an acronym for the
2:38main components of the note and
2:40presentation the S is for subjective
2:42which is what the patient is
2:44experiencing the O is for objective
2:47which is what you as the clinician have
2:48observed the A is for assessment what
2:51you think is going on and the P is for
2:54plan what you're planning to do about it
2:57as with the hmp the assessment plan are
3:00often bundled
3:02together unfortunately while it's a
3:04little catchy the soap acronym leaves
3:07out three components of the format the
3:10first is the ID line often known
3:12colloquially as the oneliner which
3:15serves to reintroduce The Listener or
3:17reader to who the patient is the second
3:20is the overnight events and the third
3:23included in the note but not in the oral
3:25presentation is the full list of active
3:28inpatient medications this med list is
3:30imported automatically by the EMR is
3:33rarely if ever edited and I won't be
3:36discussing it further but I will go
3:38through each of the other six sections
3:40one at a time first up is the ID Line
3:45This is one frequently runon sentence or
3:47runon sentence fragment that summarizes
3:50the patient's condition diagnosis if
3:53known and or reason for continued
3:56hospitalization it should be brief and
3:58to the point
4:00the ID line of the soap is roughly
4:02analogous to the chief complaint of an
4:05h&p importantly as the patient condition
4:08evolves over time the ID line should be
4:11routinely updated with new
4:13information however the ID line is also
4:16often imported into the note template by
4:19the EMR as the ID line has been entered
4:22into the chart in another location so
4:24routinely updating it it takes an extra
4:27cognitive
4:28step let's take a look at some examples
4:31of good ID
4:33lines a 61-year-old woman with COPD and
4:37Hef or heart failure with reduced
4:39ejection fraction initially presented
4:41with severe community acquired pneumonia
4:43and COPD exacerbation requiring one week
4:46of mechanical ventilation excavated 2
4:49days ago now slowly
4:51recovering a 46y old man with a recent
4:55diagnosis of stage 1 colon
4:57adenocarcinoma now posttop day three has
4:59post a right hemicolectomy Complicated
5:02by injury to the right
5:04urer an 88-year-old man with Advanced
5:06dementia oriented only to self at
5:09Baseline admitted with acute es schic
5:11left MCA stroke Complicated by Aphasia
5:14and hemiparesis made Comfort Care
5:17yesterday and now awaiting sniff
5:18placement for inpatient
5:21hospice and last a 31-year-old woman
5:24with alcohol dependence and a history of
5:26withdrawal seizures admitted for
5:28monitoring during acute detox
5:30now 24 hours status post her last drink
5:33and doing well on standard seawat
5:36protocol I now move on to overnight
5:38events these consist of anything since
5:41the last update either via presentation
5:44or note which required a clinically
5:47relevant and unexpected change in plan
5:50the reason that overnight is at
5:52initation marks is because these events
5:54don't necessarily happen overnight for
5:57example if you last rounded with your
5:59team at 10: a.m. on Monday and the
6:01patient then had a rapid response team
6:03call for acute respiratory distress at
6:052: p.m. that afternoon if the team next
6:09formally rounds with the attending
6:11position at 10: a.m. on Tuesday that
6:14rapid response call despite being 20
6:16hours ago should still be included in
6:20overnight
6:21events some examples of what might
6:23constitute an event that belongs here a
6:26significant change to the patient vitals
6:30the new onset of altered mental status
6:32such as delirium a significant fall
6:35which I would arbitrarily consider to be
6:37one that warranted a bedside evaluation
6:40by the covering
6:41clinician surgery even if it was
6:44expected belongs under the
6:46events as well as an unexpected bedside
6:49procedure such as a thoracentesis or
6:51Lumber puncture or any procedural
6:55complication last any new indication for
6:58non aasap posit pressure ventilation
7:00antibiotics IV fluid or blood
7:04transfusion there is one more thing to
7:06discuss with the overnight events
7:09specifically when documenting them in
7:11the written note it has become common
7:14practice at some institutions including
7:16my own for the overnight events section
7:18to not just be limited to the preceding
7:2124 hours but to instead become a running
7:24list of all events that have happened
7:26since admission including major changes
7:29in the status of the patients which may
7:32not have been explicitly included in the
7:34overnight events for an individual
7:35relevant day so for each Daily Progress
7:38note the writer copies and pastes the
7:41list of events from the previous day
7:43note and then just adds whatever has
7:45happened since while this practice
7:48significantly adds to the overall length
7:50of the note which is generally a bad
7:52thing it does make it easier to
7:55understand the sequence of events in a
7:58patient's hospitalization
7:59when either you are joining the
8:01patient's team far along into that
8:05hospitalization or when you're tasked
8:07with writing a discharge summary for the
8:10hospitalization that may extend back
8:13weeks or even months before you
8:15personally first met the patient
8:16yourself so while some faculty frown on
8:20this practice I think it's perfectly
8:22fine and arguably even preferable now we
8:26are at the subjective section this is
8:28where the clinician describes
8:30how the patient is feeling any new
8:32symptom should be identified and
8:34described and any symptom present the
8:36previous day should be addressed with an
8:39update for example if the patient was
8:41experiencing shortness of breath
8:43yesterday is it still present today and
8:46if so has it changed in any way even if
8:49not a symptom per se some clinicians
8:51will comment here on appetite meal
8:53intake bowel movements the ability to
8:56pass gas for postoperative patients and
8:59even how much the patient has walked
9:00around on their
9:01own although the subjective section of
9:04the soap seems a little like the HPI of
9:06an hmp it should be much briefer unless
9:11there has been a dramatic change in what
9:13the patient is
9:16experiencing the objective section of
9:18the soap has two subcomponents the first
9:21of which is the physical exam this
9:24should be very similar to the physical
9:26exam section of an h&p report
9:28observations objectively using proper
9:30medical terminology in the written note
9:33every observation and maneuver that was
9:35performed should be included in the oral
9:38presentation you should focus on only
9:40those findings that are most centrally
9:42relevant to the patient's diagnosis or
9:46condition for both report Vital sign
9:49ranges and the ins and outs for the
9:51preceding 24 hours except for the
9:54temperature temperature is usually
9:55reported as the TX or maximum
9:58temperature in the last 24 hours and the
10:01T current or the most recent temperature
10:03reading only in patients with clinically
10:05relevant hypothermia should you ever
10:08mention the minimum
10:10temperature last and most importantly
10:12for the exam the physical exam in both
10:14the note and the presentation must be
10:17tailored to the individual patient one
10:20of the most consistent errors that
10:22trainees and Senior clinicians alike
10:24make is performing a nearly identical
10:27exam on every hospitalized patient every
10:30day at best this is a waste of time and
10:34at worst at worst it leads to missed
10:37findings that aren't even checked I
10:39covered this a little bit in the hmp
10:41video when I showed this documented exam
10:43and discussed how findings can be
10:45identified as those providing insight
10:47into the patient's overall
10:49condition those that are relevant to the
10:51primary
10:53diagnosis those that look for
10:54complications of the primary
10:57diagnosis and those that valate the
10:59status of the patient's pre-existing
11:01chronic
11:02conditions you should do something
11:04similar for the daily updates in
11:06hospitalized patients though as a
11:08general rule that exam can be briefer
11:11for one thing most chronic conditions
11:13are unlikely to change significantly
11:14from one day to the next but you do want
11:17to consider what daily Maneuvers and
11:19findings are indicated because of that
11:22specific patient's acute
11:24diagnosis a few examples of what I mean
11:28for a patient with acute decompensated
11:30heart failure or acute coronary syndrome
11:33exam Maneuvers that are often neglected
11:35include looking at the jvp or IBC on
11:39point of care ultrasound to estimate
11:41right heart pressures and the subjective
11:43assessment of extremity temperature and
11:45capillary refill as very rough
11:48surrogates for profusion and Vascular
11:50resistance for a patient presenting with
11:52a complication of decompensated therosis
11:55always check for asterixis each day
11:58which is a sign of worsening hepatic
12:01incopy in patients with bacteremia and
12:03sepsis a quick skin exam to look for
12:06ptii and eimos that could be a sign of a
12:09dysfunction of platelets or the
12:10coagulation Cascade which can complicate
12:13sepsis for patients with an acute stroke
12:16please please please do a daily neuro
12:19exam that is more than just the pupilary
12:21reflexes and extraocular muscle testing
12:24this is presumably not an issue on
12:26neurology services but for some reason
12:29internists and Internal Medicine
12:30residents don't do good follow-up neuro
12:33exams on stroke patients one caveat is
12:37that sensory testing is usually skipped
12:39in the daily exam unless the patient is
12:41voicing sensory
12:43symptoms and the last example for
12:46patients with severe pancreatitis be
12:48sure to do a skin exam of the abdomen
12:50and flanks as this could reveal bruising
12:52consistent with pancreatic Hemorrhage
12:55this is just a tiny subset of daily exam
12:57findings that may not be indicated for
13:00all patients but are definitely
13:02indicated for
13:03some having gone over that there are
13:06some exam Maneuvers to check in all
13:08inpatients every day though this
13:10specific list is debatable I know plenty
13:13of clinicians who advocate for more than
13:15this and a smaller number who advocate
13:18for less but in my opinion this list
13:21includes the vitals eyes and nose even
13:24if there's just a qualitative record
13:27only like three trips to the bathroom
13:29room and 50% of their meals mental
13:32status which doesn't mean a formal mocha
13:34mini Cog or mini mental status exam
13:36every day if the patient's level of
13:38Consciousness speech language and
13:41thought process are all normal based on
13:43your routine conversation with them
13:45that's sufficient for the daily exam but
13:48if any of that seems off or if it was
13:51off the day before a little bit more
13:53testing a little bit more thorough
13:55testing is warranted such as tests of
13:57orientation a tension and
14:00memory lung oscilation primarily to
14:03listen for crackles that could indicate
14:05the development of pneumonia silent but
14:07clinically relevant aspiration or volume
14:11overload and assessment for dbts in the
14:15legs additional Maneuvers that some
14:17clinicians recommend for all patients
14:20include cardiac oscilation and palpation
14:23of the abdomen and among Chans who
14:26advocate for an even shorter exam you
14:29usually lung oscilation is what they
14:30would cut out stating that any pulmonary
14:33finding of relevance would necessarily
14:35be preceded by the patient reporting a
14:37respiratory symptom that would prompt
14:39the exam in those cases anyway which I
14:43think is a reasonable
14:44point the second part of the objective
14:46section is for Diagnostics or tests for
14:50an oral presentation only highlight new
14:52results that are relevant to today's
14:54assessment and plan please do not read
14:58off all 25 new blood test results every
15:01morning for every patient however if a
15:04patient is appropriately on Telemetry
15:07meaning they have a good indication for
15:09continuous ECG
15:10monitoring that data is always relevant
15:13enough to summarize for the presentation
15:16even if that summary is as brief as on
15:18Telemetry the patient remained in sinus
15:20rhythm 100% of the
15:23time for written soap notes include uh
15:26include all new results most of which
15:28will be automatically imported into the
15:30EMR template for radiology pathology
15:33tests for both presentations and notes
15:36summarize the report rather than either
15:38reciting them verbatim or copying and
15:41pasting the entire report into a note
15:43while there are times in which copying
15:45and pasting an entire Radiology or
15:47pathology report into the discharge
15:50summary is appropriate it is never
15:53needed in a Daily Progress
15:56note after the O comes the a for
15:59assessment as mentioned this is a
16:01summary of what you think is going on
16:02with the patient overall it's relatively
16:05similar to the assessment of the hmp
16:08except with less emphasis on the initial
16:10presentation particularly if a diagnosis
16:12has been established the assessment
16:15should contain analysis and
16:17interpretation of new data unless the
16:19patient is completely stable and
16:21unchanged from the previous day an
16:24assessment can be as short as a single
16:25sentence or as long as several
16:27paragraphs depending on
16:31circumstances and last is the plan
16:34although the P could also stand for
16:35problem list since that is the form in
16:38which the plan is provided the Soaps
16:41problem list follows the same general
16:43principles as the problem list from the
16:45initial hmp but for a soap oral
16:48presentation only include those problems
16:50that are relevant to the current
16:52hospitalization unless it's the day of
16:54discharge in which case you should list
16:56all of them be sure to revise the
16:59problem list each day this means add new
17:02problems remove problems that are
17:04completely and totally resolved and
17:07reorder problems as their urgency and
17:09priority change although I spent much
17:12longer on the preceding four components
17:15the assessment and plan are the most
17:18important parts of the note and
17:20presentation even if they are relatively
17:22brief in absolute terms and that is how
17:25many words they take up this is where
17:27you should spend the majority of your
17:29cognitive effort I'll end with some
17:32common pitfalls with so presentations
17:33and notes the ID line is not updated
17:37overnight events are missing which
17:39usually happens because the events were
17:41in the preceding afternoon and aren't
17:43thought of as quote
17:45overnight the subjective section is to
17:48verbose the physical exam has been not
17:51appropriately focused on findings that
17:53are clinically relevant to the patient's
17:56specific diagnosis
17:59for all presentations only either every
18:01lab is recited or centrally relevant
18:04labs are
18:05omitted Labs being presented before the
18:08exam which for some reason is really
18:12common the problem list is not
18:14updated and last for both notes and
18:18presentations they are just too long
18:21overall that's it for this video on soap
18:24notes and presentations the next videos
18:26in this series will consist of two
18:28example soap presentations uh followed
18:30by a video explaining the EAP format of
18:33presentation and progress note

About this transcript

This page contains the full transcript of SOAP Notes and Presentations by Strong Medicine, generated from the public captions YouTube serves with the video. The transcript has 2,759 words across 448 segments, with the original timestamps preserved so you can click any line to jump to that moment in the embedded player.

What you can do with it

Use the transcript to take notes, quote the speaker, build a study guide, generate a summary with ChatGPT or Claude via the YouTube Summary tool, or export it as a timed subtitle file with YouTube to SRT. You can also re-open it in the transcriber to translate the transcript into 100+ languages.

Free YouTube transcript tool

YouTube2Text is a free YouTube transcript generator — no signup, no daily limit. Paste any YouTube link and get the full transcript instantly, with timestamps, click-to-jump, translation to 100+ languages, AI prompts for ChatGPT, Claude, and Gemini, and exports to TXT, SRT, VTT, or Markdown.