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Guidelines for Clinical Notes

Clinical notes expectations

Remember to record data on every patient you see in the clinic. For each patient you see, under "clinic notes," provide brief information on what the patient came in for, what they were treated for and with, and when and if the patient needs follow-up care.

Additionally, if you saw something or did something of interest (e.g. you sutured a laceration, saw a patient with a zebra disease, performed the skin biopsy, etc.), include these events in your clinic notes.

An example of what a clinical note entry might look like: "Patient is a 49-year-old male complaining of cough, runny nose, and congestion x 3 days. Patient reports claim mucus, denies any chills of fevers. Has been taking OTC multi-symptom cold prep with relief. Patient diagnosed with acute viral sinusitis. Treatment: Flonase two sprays in each nostril daily, was educated to rest, increase fluids and continue with OTC cold prep. Call office in a week if symptoms are worse or or a fever developed."

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SOAP notes

Once a week, you will choose a patient from clinical to write a SOAP note on. Do not include any identifying information on the patient. Faculty will give you feedback on your SOAP notes.

Many clinics will utilize SOAP format for outpatient notes. When writing SOAP notes, attend to the following:

  • S (subjective): only what the patient tells you (e.g. symptoms, attributions, etc.). This includes the CC, HPI, OLDCART, and pertinent positive (e.g. +FH of gallbladder diagnosis and a patient presenting with RUQ pain) and negative (immunizations or screening tests that are not current) findings read from a brief overview of the PMH, PSH, FH, SH, and ROS. Do not indicate impressions or results of your physical exam in the subjective section
  • O (objective): includes results of your physical exam and interval test data
  • A (assessment): includes your interpretation of findings from the subjective and objective data. This is also known as your diagnosis and your differential diagnosis
  • P (plan): includes what you are going to do about your assessments for diagnosis. Many providers dictate/write the assessment in the plan to gather for each individual problem

Example of a standard SOAP note:

S: "I have a rash that will not go away."

Patient is a 27-year-old female athletic trainer who presents with a red, pruritic rash on her left hand. She noticed the rash about two weeks ago and has been using OTC HC 1% cream on it BID but it is still itching and seems to be spreading. Showering and heat seem to make the rash redder and itchier. She denies any new skin products, detergents, new foods or meds. No recent travel. Her past medical history is positive for eczema, well-controlled asthma, and allergies to dust mites and eggs. NKDA. Her meds include:

HC 1% cream as above
Lo Estrin 1/35 QD
Albuterol MDI two puffs QID PRN
 Lavender essential oil topical PRN
She lives with her husband and mother, neither of whom have similar symptoms. No pets. Denies history of tobacco, occasional EtOH, rag weed, denies other recreational drug use. Her ROS him is essentially benign. LMP 2/26/23.

O: Pleasant Asian female, NAD

VS: T 98.8 P64 R16 BP 106/68

Focused Derm: skin generally W, D & I .  A 2 cm  erythematous annual lesion with dry, raised borders and clear center is noted at the base of the left thumb. No surrounding erythema. No other lesions noted. No regional LAD.

A: Tinea Corporis, DDX granuloma annulare

P:  Fungal scraping with culture to lab

Ketoconazole cream #30 gm topically in thin layer to affected area BID x 14 days.

Do not cover treated area.

Keep skin clean and dry.

Avoid sharing close, wash class, towels, etc.

Follow-up in two weeks recheck, sooner if symptoms worsen.