I decided I was in a very giving mood and wanted to give some examples of full SOAP notes. Since a chunk of you who show up to my site are here for the scribing practice and explanations, I figured I’d try to give you some more resources.
I have added a blank or a general SOAP note template here. This full out SOAP note is pretty in-depth. It would likely be used more for general wellness exams at a family practice office, internal medicine visit, or possibly a pre-operative full H&P. Many other specialties do take the same format as this note, they just don’t necessarily have as much information or as detailed of information.
Here is an example of an ENT focused note. It is not quite as in depth as the charts I used to write were simply because I can’t remember every detail of how I did those notes. The pathology for them as well is getting hazy too. I used to work in several ENT subspecialties and I have to tell you, this was one of the hardest scribing jobs I had. Each specialty was so incredibly specific yet all in the same small area of the body. I chose to do a hearing related one as neuro-otology was one of my favorite subspecialties. Rhinology/sinus was my second favorite, only because I then spent the most time here. It took me forever to cross train scribes as their providers also usually only worked 1-2 days a week. [Insert your favorite eye rolling emoji here].
Here is an example of an ortho follow up note. This one is a little more rough (I know). It’s been a hot minute since I did an ortho note so take it with a grain of salt. But basically the first paragraph you want to summarize all the previous history/surgeries and the second HPI paragraph you want to give an update for how they are doing in the office the day you are seeing them. The goal is to continue to add on to the first paragraph with pertinent information from the last visit so you have it all in one note.
Here is an example of an urgent visit note . Say from a level 3 ER case, an urgent visit at the family/internal medicine office, or possibly at an urgent care.
What are some differences that you notice between these charting types? What are some similarities? Do you notice how the more focused notes don’t have as many ROS and PE systems as a full generalized well exam would?
Look at how I tend to word my HPI’s or how I might put things in the physical exam. There are definitely some findings that can go under multiple systems on the PE; pick one for that chart or try to pick one system that you would generally put it under.
I personally liked to bold the abnormal findings when doing charts in programs that do not automatically bold them or highlight them in red. As a scribe, this is a nice touch to help your provider or other medical staff see the abnormal findings more quickly. But by all means, this is not necessary to have in your chart.
*As a side note, these will be read only. You may feel free to print them off and mark them up. Or make a copy on your own drive and mess around with them.
I was given a 3 page packing list of what to bring for this trip per the professor heading it. It was nicely broken up between what to put in our carry on and what to put in our checked baggage.
Since we were traveling for close to 24ish hours to get there, he told us to make sure we had a spare set of clothes in case our luggage was delayed. And also so, ya know, you weren’t having to wear the same dirty clothes. We left Kansas City on July 2nd, at around 12pm. We arrived in Nairobi, Kenya on July 3rd, 9pm. We then stayed the night in Nairobi, and took a small plane the next day to Kisumu. So yes, I packed an extra day of clothes lol.
There is an 8 hour delay between Missouri time and Kenya time by the way.
Flight to Amsterdam!
Recommended Carry on:
Like I said before, an extra change of clothes.
Toiletries
Medications
Passport/copy of flight/yellow fever vaccination card/visa
Snacks for traveling (I brought Kind bars and Cliff bars for the trip)
Camara/small flashlight/travel alarm clock
Small locks for suitcases
Warm fleece or light jacket.
Sunglasses/regular glasses
Converter (Kenya is type G). I honestly had no idea there were multiple types of outlets in the world. I clearly don’t leave the States much…
Earphones/earplugs (I couldn’t sleep without earplugs while I was there)
Kleenex
Binoculars
Baseball hat
Alcohol wipes/clorox wipes (Didn’t use these much on the plane because I’m fine with germs. Makes my immune system strong! But I know people who did use them)
Empty ziplock bags
Otoscope, ophthalmoscope, & stethoscope
Books/ipad
Chargers
Reminder this is for the way there. I wanted to check my instruments in my checked luggage for the way back. Unfortunately my otoscope/ophthalmoscope has a lithium non-removable battery. So it had to come with me on my carryon on the way back.
Funny story…
The year before us, the Kenyan security/cops at the airport had pulled a student over to the side because they accused him of having a sex toy in his carry on, when in reality it was just his otoscope kit. The said student freaked out, and he was questioned for a bit. Big headache for our amazing professor who brought us lol.
Well the Kenyan security/cops also stopped me because they thought the same thing. However instead of freaking out, I just started pulling it out AND THEY STARTED FREAKING OUT. NO NO NO! Shaking their hands at me. LOL. I’m a hoot.
One of my classmates explained to them as I was pulling it out to show them that it was for looking in ears and when I put it together and turned it on they were less upset.
Anyways. Turns out I’m still a spicy meatball in another country lol. Also don’t bring sex toys in your carry on.
What I packed for my carryon:
Mostly all of that. I also packed:
I packed an additional 2 pairs of undies, 2 pairs of socks, 2 sports bras as part of my additional clothes. I have packing cubes and I just used a small one to put all my clothes in.
I packed my sleep mask, an RFID safe wallet, a safety travel belt (so I can most importantly keep my phone and passport on my person under my clothes at all times). I probably could have put the belt in my checked bag, but it didn’t take up much room.
I also brought my digital camera. And because my camera is a bit old (2011), I also brought the battery charger for this in case it ran out while I was there for 3 weeks.
Oh, and lip balm. Because you girl wants to make sure she doesn’t end up with 3rd degree burns on her lips this summer like last summer.
That’s a story for a different time.
Recommended/Brought Vs What I used, checked baggage:
What I packed
Did I use it?
9 pairs of underwear
Yes I used this. It helped not feel so gross.
6 pairs of running socks
Yes
6 pairs of hiking socks
Honestly, didn't need this many. Running socks would have been fine
2 Thicker pairs of socks
Didn't need. I was just being cautious
3 sports bras
Yup. Honestly, could've used more since I wore mostly these
1 nicer bra
Yes for when I wore nicer clothes
3 sets of scrubs
yup. I wore these everyday at clinic. Don't recommend more, just reuse them. If you don't wish to take them home, you can usually leave them at the clinic.
3 pairs of shorts (2 nice, one workout)
Honestly 1 pair would have been fine. I did use the workout shorts a lot
1 pair of jeans
I maybe wore these one night
1 light weight pair of pants
Yup. These were nice and breezy. Wore them a lot
1 pair of fishing pants/cargo pants for safari
yes.
5 t-shirts
yes. for both leisure wear and for running in
low cut hiking/trail shoes
I used these to run in, hike in, and at clinic (needed that ankle support)
2 leggings (I wore one on the plane)
Yes. For mostly running in and traveling
3 workout tanks
yes. for both running and leisure
sleepwear
yes. but it was basically a pair of cheer shorts and a tank so... I could use those outside of sleeping if needed
swimsuit
yes. but I only went swimming once. Some people swam more
3 dresses + 2 coverups
I had 3 sundresses. We had several occasions where we could be more dressed up/wear a dress
safari hat
must for me. I was on antibiotics
flip flops
I mainly wore them around the hotel. but I didn't wear them much outside of that
2 sweaters
I probably didn't need the second one as I had another one on my person while traveling.
Wore on the plane. Wore intermittently on my trip if I didn't want to wear hiking boots
long sleeve shirt
I wore this on the plane. I would wear it periodically if I got col
2 giant bottles of sunscreen
Was being cautious. I really only needed one. Gave an extra one to some Kenyans
4-5 large spray bottles of 40% DEET bug spray
Recommend bringing wipes and maybe a smaller bottle. If you don't spray/soak your clothes before leaving, then bring a bottle or two. But I didn't need this many and gave it away to a few Kenyans before leaving.
I know this is a long list. And honestly I spent way too long trying to figure out how to best compare/present this information to you. My apologies if it isn’t the best way to be represented.
I brought a lot of sunblock, giant safari hat, and baseball hat because ya girl was on doxycycline (which is a bitch when you are already very white and prone to sunburns in the first place) and I didn’t want to get too sunburnt. There was a running joke that I was khaleesi (I had super white hair on this trip) because I managed to NOT get sunburnt with the amount of precautions I took.
Yay me!
For the most part of the packing list we were given, I stuck to getting everything on it. I added additional underwear, socks, and a few additional clothing pieces just because I am an overpacked and was unsure of what I would need in Kenya…
For shoes, most people just used their running shoes in clinic, to run in/exercise in, and on their hikes. I preferred to use my low cut hiking trail shoes as the roads were not all flat and I wanted extra stability for my ankles. PLUS, if they got muddy while in clinic it was less annoyed by it.
I did however bring several flushable wipes (not on the list), a small first aid kit, face cream, body lotion, hairbrush, hairties, q-tips, a razor (just in case because I did bring a bikini), an extra travel toothbrush, a few pills of Advil, probiotics, and I brought 2 additional travel size containers of shampoo and conditioner. (I have a lot of hair, I mostly need a lot of conditioner since its semi curly and just doesn’t every listen to what I want it to do…)
Oh, and tampons. Because of course I started right before we left for Kenya. But hey, at least I won’t be expecting it unexpectedly while there right?
That is what I told myself anyways.
I then looked back at some old notes when we had our very first meeting together, and also packed a beanie, peanut butter, a little bit of laundry detergent, and melatonin ( I think I brought 20 pills?) per those requests. I didn’t use the beanie or laundry detergent (this was going to be hit or miss when we arrived), but I def used the peanut butter and melatonin.
Prior to leaving:
I stayed a long weekend at my besties place as she still lives in KC. Since we all had to leave from KC’s airport together for this trip and I now live in Joplin, I headed up early to spend some time with her and her husband. I also wanted to give my cat a few days to acclimate to being in their apartment, since they were kind enough to watch her for me while I was gone!
Because I didn’t want to deal with unpacking or repacking things for my checked bag OR my carry on, I actually brought a separate bag. It’s usually the one I bring when I go up to the city to spend time with her. This brought an additional 2-3 sets of clothes and some extra undies and socks. I also brought an extra bathing suit/towel since they have a pool. I also spent 2-3 days with them after returning. This gave me time to slowly acclimate back to central time and recuperate a bit from traveling before heading back home.
This served to make sure I had fresh clothes for both before and after my trip. I will also leave my computer in their apartment, just so I can use it while they are away at work. Plus, I want to be able to blog the memories while they are still fresh! (Side note: this did not happen. I’m finishing this post in January 2020…)
Kitty prep!
In case you are curious, I’ll just add what I brought with me for my cat lol. By all means, this is of no importance to ya’ll, just something fun!
A box of canned kitty food (turns out they make these now?). I brought the box that had 30 cans instead of the box with 48. She doesn’t need 30 cans of cat food, but it was just easier to carry the whole box. Especially since we will be there a few days before I leave and a few days after.
Her dry food bucket
2 dishes
Her food mat (she’s a messy gal)
Her litter box (I got her a new one. We don’t have a hose so it’s hard to clean out her current box. It’s also easier to bring a clean one there so it saves space on the travel north.)
2 things of litter
Litter catching mat & scoop (again, she’s messy)
Her bed
Her favorite play toy
Brush (because she sheds like a mofo and my bestie really likes a clean apartment).
AND her favorite kitty nip toy + kitty nip. I forgot this last year and I think she will feel better with it.
And then obviously her carrier because I need some way to transport my little monster.
And that’s it. It’s not everything for my cat, because she’s a spoiled brat and has way too many toys and bags and boxes at our house. But, it should be enough to not only cover the basics but make her feel more at home. I anticipate a chunk of the canned food to be gone and a chunk of the litter to be used before the trip back. Which means less bulky things to bring back!
Let me know if ya’ll found this helpful for your trips abroad! Cheers.
