Thursday, August 23, 2012

SOAP Note Template

This page is dedicated to offer medical students a simple and easy to use SOAP note template for clinical rotations.

After clinic today I really felt the need to have some sort of way to record my notes so I created a pretty sweet clipboard & SOAP template setup which I would like to share with you.  You can see my template on the clipboard in the pictures I have included.  More importantly I have included the template for you to download.  Now the super cool thing about this template is your can fit it in your white coat pocket on a reduced size clipboard (Officemax ~$2).  I have also included a short youtube video on (1) the outline of the template (2) how to edit it for your own use.

1. Buy a small clipboard
2. DOWNLOAD one of the following templates:
  • Peds indexcard template (Peds 1.0)  CLICK HERE TO DOWNLOAD
    • This template is very similar to the next one below (Adults 2.0) with the addition of a section to just "mark off" your physical exam findings.  I finalized this one in MSWord and printed it on 5x8 index cards.  I like it.  You can use this for adults as well, there are just some minor corrections which could be made for adults.
  • Large indexcard template (Adults 2.0) CLICK HERE TO DOWNLOAD
    • This updated template includes two locations for CC&HPI as well as an expanded section for medications with both dosage and frequency as well as other updates.  Make sure you print this one on 5x8 index cards.  It does not have the detailed physical as shown a
  • Large indexcard template (5x8 for abo. $5 at Officemax)
    • Questions regarding mammography and colonoscopy added.
  • 1/2 sheet of paper template (5.5x8.5 to be custom cut)
    • Rather than printing on a 3x5 card (as above) this can be printed on modified 1/2 sheets (1/2 of 8.5x11).  In the end, I trimmed a little off the bottom after printing.
3. Print off the template on to your medium of choice (depending on your template).
4. Paste the ROS questions part to your clipboard for reference
5. Enjoy! (may want to use a fine tip pen ie. Pilot G-2 0.38)
6. Edit it for your own benefit and send me a copy -of your new and improved- so I can benefit too!

The youtube video gives an (1) outline of the template (2) how to edit it for your own use.