H&P AND DAILY PROGRESS NOTES A detailed note on every new admission should have five components: 1.

History 2. Physical examination 3. Relevant lab results 4. Assessment 5. Plan The daily progress note should be written in the SOAP format, as follows: Subjective Objective Assessment Plan S (SUBJECTIVE) Under this head you should write the subjective feelings of the patient. These should be written verbatim as far as possible: I couldnt sleep last night. I havent moved my bowels for 5 days, When can I go home, doc? Ive got a lot of things to take care of at home. You should give the pride of place to the patients concerns in this section, even if you feel they have nothing to do with the admitting diagnosis. You should also put a lot of your effort toward taking care of your patients complaints or concerns. O (OBJECTIVE) You should write down your physical examination findings here, followed by the lab results. A (ASSESSMENT) Under this heading, you should write what you think about the overall condition of the patient. This is the place where you can write what you think about the diagnosis and the rationale behind your decision. For example, suppose you have a patient with a complaint of tiredness and anemia. You can write, I suspect hematological malignancy as the patient has marked splenomegaly and lymphadenopathy. You should discuss different problems under different heads. An example is shown below: Congestive heart failure (CHF): Patient is know to have CHF. This episode may have been precipitated by atrial fibrillation. Feels better today as compared to yesterday. Hypertension: Well controlled. The patient says her BP has been around 120/70 on measurements at home. High BUN: Possibly due to aggressive diuresis. Diabetes mellitus type 2: Poorly controlled. Blood sugars have been between 250 and 350 during the hospital stay. P (PLAN) In this segment, you should write how you plan to deal with all the issues enumerated previously under the assessment. The plan can be in the form of medications, investigations, referrals, and so on. Continuing with the example given above, you might write the following: CHF: Will continue diuretics and ace inhibitors. Will decrease the dose of diuretics in view of satisfactory diuresis and rising BUN. Will start small-dose beta blockers and increase as tolerated. Hypertension:Will continue same medications. Rising BUN: Will watch for response to decreased dose of diuretics. DM type 2: Will call endocrinology consult for help with sugar control.