History and Physical Advice Tips Secrets

Progress SOAP Note

S: patient comments or complaints, nursing comments.

O: VITALS: blood pressure, pulse, respirations, temp, weight, O2 sat.

INS/OUTS: IV fluid, PO intake, emesis, urine, stool, drains.

EXAM: physical findings.

MEDS: pertinent routine or new medications.

LABS: new laboratory or procedure results, not old information, just most recent.

A: assessments based on above data.

P: medication changes, lab tests, procedures, consults, discharge, etc.




History & Physical


Common Night Calls

Patient Tracker Sheets

Antibiotic Guide

ABG Calculator

Drug Guide

Medical Notes:
Admit/Transfer Orders
Progress (SOAP) Note
Discharge Summary
Procedure Note
Discharge Summary
Off-Service Note
Pre-Operative Notes
Operative Note
Post-Operative Note
Death Note
Post-Partum Note
Delivery Note
Cardiology Progress Note and Consult

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The money is in the assessment and plan!