4 th Street Clinic SOAP Notes Workshop

1. Presented by: Dr. Susan Cochella and the 4th St. Clinic Managers 4th Street Clinic SOAP Notes Workshop

2. Supervisor: Dr. Susan Cochella Tammy Nguyen, MD/PhD Candidate Jillian Wong, MSII SandhyaRavichandran, MSII Henry Tran, MSII Chris Rees, MSII Alex Meier, MSII Cody Martin, MSII Katherine Poruk, MSII Breton Yates, MSII Giang Tran, MSII 4th St. Clinic Managers

3. Your Managers for 2009 - 2010

4. A nonprofit organization that works to end homelessness by providing comprehensive health care and support services to homeless Utahns. For many of their patients, they are the first and only chance at proper diagnosis and treatment. What is the 4th Street Clinic?

5. Fourth Street Clinic is a full-service health home that offers coordinated primary care, behavioral health and pharmacy services. Forty staff members, 35 in-house medical volunteers and over 200 off-site specialists who see patients on a pro bono basis and serve nearly 6,000 patients each year. What is the 4th Street Clinic?

7. The Saturday Student Clinic!

8. The Saturday Student Clinic • Each Saturday, Medical Students are allowed to staff the clinic. • Made up of primarily MS1 and MS2 students who, along with a volunteer physician, treat homeless patients. • Clinic runs each Saturday from 9:00 am to approximately 12:00 pm.

9. What do we do? • Vital Signs • Patient history • Physical Exams • Write and present SOAP note to attending physician • Observe physician diagnose and treat patient • Dispense any treatment necessary

10. What do we see? • We see adults with a variety of illnesses: • Colds/Respiratory Ailments • Cardiovascular Problems • UTIs • GI ailments • Diabetes related problems • Headaches, Ear aches, Muscle aches • And other general primary health concerns.

11. The Benefits • Opportunity to work with at need populations in the Salt Lake Valley. • For many, it is the only opportunity to get hands on experience with patients. • Allows students to practice skills such as taking a patient history, writing a SOAP note, and performing a physical exam before starting 3rd year rotations. • Meet local physicians

12. The 4th Street Schedule and How to Sign Up

19. Red = Clinic Full Blue = Can Sign Up

24. Things to Remember!!!

25. You are only allowed to sign up and attend 2 clinics per month! • If you find you cannot attend a date you signed up for and it is within one week of the clinic, you must find a replacement!

26. What to wear? • Dress professionally! • Men: • Nice shirt and slacks • tie optional • Women: • Skirt or nice slacks • No Jeans!

27. What to bring? • Stethoscope • Name tag • Pen • You do not need your white coat.

28. Recognition: • If you attend 8 clinics in between now and August 2010, it will go on your Dean’s Letter. • You can have it listed on your Dean’s Letter for both MS1 and MS2, provided you attend 8 clinics each year. • We will look for new managers in Spring 2010.

29. Questions?

30. Familiarizing You to the Computer Software

31. Entering the System

32. Patient History

33. Vital Signs

34. Encounter Note/ SOAP

35. Prescription Orders

36. S.O.A.P. Note with Dr. Cochella Writing S.O.A.P. Notes Chief Complaint – in patient’s own words S = SUBJECTIVE: (What the patient tells you.) History of Present Illness Onset, Duration, Severity Associated Symptoms What Worsens?/Improves? Treatments?/Outcome? (including alternative and OTC) Past Medical History Illnesses, Operations, Allergies, Medications Preventive Health Update OB-GYN for Women (including FP/BC) Family History Social History Living Situation/Family Alcohol, Tobacco, Drugs Occupational History – Jobs, Exposures, etc. Review of Systems

37. S.O.A.P. Note with Dr. Cochella 0 = OBJECTIVE: (What you document.) Physical Examination Laboratory, X-rays Special Procedures/Tests Consultation Results/Reports A = ASSESSMENT: (Problems Identified/Presumed Diagnosis[es]) P = PLAN: (What you [and the patient] plan to do – note the three distinct areas) 1. Further Diagnostic Evaluations (Studies/Tests/Referrals) 2. Patient/Family Education 3. Treatment: a. Non-Pharmacologic (rest, exercises, diet change, weight loss, heat/cold, etc.) b. Pharmacologic (both prescription and OTC) c. Preventive (age appropriate recommendations: counseling, screening, Rx, etc.)