Drake’s Clerkship Survival Guide
Writing Progress Notes
Introduction
寫病歷是 clerk 學習最重要的途徑之一，你多寫，人家就知道你腦筋裡裝的東西有沒有出問題。
Progress note 和 admission note 不一樣，是病人住進醫院後，每天再去看看他時寫的 note, 主要是用
來記錄病人的變化、病程 progress 的改變，故名。
SOAP notes
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Drake’s Clerkship Survival Guide
Explanation
首先，記得要寫上記
錄的日期和時間。右
上角可以寫上病人正
在使用的抗生素是哪
種？已經使用第幾天
了？另外同樣重要的
是如果病人有接受什
麼手術，術後第幾天
也一樣要寫在前面，
好讓人一眼就知道病
人的重要狀況。
Object 方面要把最重
要的 vital signs 擺在
前面，後面接著寫下
去要依照次序。
Labs 的資料可以直
接抄，左邊的寫法是
國外在用的，我們醫
院裡沒人這樣子寫
的。
一開始 PE 寫出來是
越詳盡越好，漸漸你
就應該知道要寫重
點，至於哪些是重點
就要靠自己去學了。
重要的是記得在病歷的最後簽上自己的名字並請人幫你 countersign. 像這樣子：
Clerk 謝慕揚 / VS 王小明. 框起來的部份是你寫的，劃底線的則是請人幫你簽的。
整個 note 最重要的部份在 assessment 的部份。
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Drake’s Clerkship Survival Guide
Tips on writing SOAP notes
The heading of the progress note should include the date, time, who is writing the note (CC3, CC4,
PGY1, Chief Resident etc.), and the service (Red surgery, Gyn, Neurology etc.). Always list the
antibiotics and what day of the antibiotics at the top of the progress note along with other meds and
doses.
Subjective information is what the patient tells you. How are they feeling? What are their
symptoms? What are they eating (if NPO, note it here)? Are they sleeping well? Are they
ambulating, urinating, defecating, passing gas? If they have diarrhea, describe it here (e.g. "green
and watery x3 last night").
You have already learned to clarify a chief complaint, which is also subjective, and you should ask
the same kinds of questions to clarify the subjective information. If a patient tells you he is "doing
poorly," you should not write this in your note (this may be construed as your assessment). Get a
good description of the symptoms, and write: "Pt. c/o (Patient complains of) abdominal distention
and pain in right shoulder exacerbated by inspiration and change of position/exertion."
Objective information is what you gather from your physical exam and from other tests. Begin
with the vital signs. Also include total fluid input and output over the last shift (I's & O's) if the
patient is NPO or on a diuretic regimen. You should also record the patient’s weight if daily weights
are being recorded. Then write your physical exam including only pertinent positives and
negatives. What is considered "pertinent" will also change for each rotation, so be prepared for
feedback.
After the exam, write the results of laboratory tests which have not yet been entered into the
chart. The shorthand format for writing lab results is as follows: draw the grids shown below and
then fill the lab value in to the spaces- e.g. the Na value should go in the upper left hand corner of
the grid below. This saves you the trouble of writing "Na, K, Cl, BUN," etc many times each day.
There is also a complicated grid some people use for LFTs, but you are better off just writing them
out unless your house staff tell you otherwise. After the labs, include the results of other studies
which have not yet been noted in the chart. These include EKG, x-rays, CT scans, etc. If a lab or
test has been ordered but the results are not yet back, note that the test is pending.
The assessment is what you think is wrong with the patient. Your assessment should make it clear
that you understand the crucial differential for each problem- but don't include the differential unless
your house staff approves. This is the most important, and difficult, part of the note, so get as much
feedback as possible. The assessment is also a summary of how the patient is doing and what has
changed from the previous day. For example: are they defervesing, are they still with symptoms,
has their white count improved etc.
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Drake’s Clerkship Survival Guide
The plan is what you are going to do about each problem such as medication, labs to order, tests to
obtain, consults that should be called.
Most people put the assessment and plan in one section (A/P). One way to organize the A/P section
is to divide it into systems (FEN, CV, Pulm, ID, Neuro etc) as shown in the example. Another way is
to make a problem list for the patient beginning with the most serious problem. Again, the format
you use will change for each rotation. The surgical style SOAP note applies to the general surgery,
gynecology, and urology clerkships. You will not be writing notes in ENT surgery, neurosurgery, or
orthopaedic surgery. The most important feature of the surgical SOAP note is its brevity. The
residents will inform you if your note is not to their liking and you should adjust your style.
Footnotes
上面的文章是我在美國某大學的教學網頁裡找到的，希望能讓你搞懂寫 note 的重點在哪裡？
這篇 How to Write Progress Notes 不可能讓你把 note 寫得很好，但起碼能讓你提筆知道該寫什麼，
並有信心寫下去。一篇 progress note 不值得你花一大堆時間〈超過一個小時〉寫還寫不完，趕快寫
完請個學長或學姐幫你看。不用怕被改得亂七八糟，改過了下次就會寫得好，不會再漏東漏西的。
最早的 SOAP 的構想是個美國的醫生提出來的，他認為 problem-oriented note writing 可以幫助
學生釐清病人的身體變化，可以幫助醫學生早點抓到疾病處理照顧上的重點，並培養思考的能力。
理想的 bedside 學習方式是在短時間內 〈少於二十分鐘〉觀察完病人〈聊天 or PE〉並寫完 progress
note. 接下來馬上跟人討論你有疑問之處。這時通常你也會學到哪些你所考慮的是否有真正的
clinical significance, 而其實哪些疑問根本就是 nonsense. 接下來，練習做 differential diagnosis.
Clerk 最重要的是學習如何 approach 病人，並選擇正確的方式建立診斷。
Clerk 最常見的問題是找不到適當的辭彙描述自己所觀察到的現象。Clinical diagnosis 其實一開
始都很難判，最初為了病房見習，應多閱讀描述 signs & symptoms 的書。書上若附有大量且詳盡的
照片，則該書便是 first choice. 影片方面，可以用 Harrison’s Principles of Internal Medicine CDROM
裡的影像補強。為了便利自己在病房裡的工作，加強自己 clinical diagnosis 方面的字彙是最重要的
事。寫 note 最常碰到的困難，就是停下來想： 「這個現象我要用哪一個 term 來描述？」 And this is
the most exhausting part of note writing!
如果說到了五年級還在念生理病理機轉方面的書，是很浪費時間的，所以病理和生理一定要讀
好。