Soap Notes: The Down and Dirty on Squeaky Clean Documentation

Pretty good

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 The information presented in this book is often outdated and irrelevant to notes written in an electronic medical record, or it reflects something I am not physically able to do on the computer. The book is outdated; it does not even touch on the topic of how to document and write effective notes in an electronic medical record.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.

This book makes writing soap notes really easy. It breaks each section down and provides examples of what each section should look like. Even though I used it once, it was a great resource to have.

I inadvertently gave the wrong feedback- this book is great. It is concise and easy to read and it is helpful for my use.

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.

Just what I needed...

These are medical notes

Very helpful to learn to write SOAP notes

I found this little book to be an extremely helpful resource in learning how to write SOAP notes. As a massage therapist in the UK, you are rarely taught how to write up proper notes that are appropriate when working alongside Physiotherapists, Osteopaths, GP's and Consultants. Although this book doesn't contain everything it is a great starting point and a helpful reference.

Very good book