SOAP NOTE HELL

I truly believe I have found myself in S.O.A.P note hell and constantly asking myself "what in the world have I gotten myself into" and craving a glass of wine.  Our last assignment was to watch an OSCE video, and to complete a clinic note (from what I could actually see).  So, my first rant - the video was in 3 parts each 20 minutes long. Who in the world has a 60 minute OSCE (sign me up for that program) because we have 25 minutes with a 5 minute break before moving on to the SECOND encounter that is also 25 minutes. Secondly, the chief complaint must "yearly checkup", seriously?! I am sitting here scouring Bates, Pagana & Pagana, for the appropriate care r/t to a chief complaint of something as vague as "headache" or "jaundice" or "unintentional weight loss" and this kid gets "yearly checkup"!!  Lastly, I couldn't see 3/4 of the things he was doing as his back was to the camera and he didn't say them all out loud so yes i can ASSUME he was palpating/percussing the liver. Ok, now that I have shared rants ... I am left completing this assignment. I spent 4 hours yesterday looking up the name of tests and medical terminology to fill in the ROM of the note (that i completed from intake forms the patients were given). Talk about feeling like a moron, but I am not sure I have ever had to chart the medical term for occasional muscle weakness and so on). I wont even start to rant about how many times I wish I would have just dove into medical school 10 years ago rather than nursing and now NP but life apparently had other plans for me, and so here I am. I honestly think we were given this assignment to have us scour the pages of Bates ... at this point I am pretty sure I have read nearly EVERY page in that book. Still, I feel a tad bit clueless. The only abnormality I found was that my patient had a BP indicative of stage one hypertension and a family hx. So, 3 pages worth of Subjective & Objective information gets me 1. Yearly Checkup 2. Hypertension ..... my treatment plan will be next to nothing. My conclusion, our instructors have absolutely NO faith in our assessment skills (sigh) and I am starting to agree!!

17 days and counting until the dreaded OSCE and I still have to find time to practice a few vaginal exams on the plastic pelvis before we're asked to complete one on the spot (i am still trying to figure out who says as a child "when i grow up I want to be the vaginal exam practice patient") but thankful for them i suppose. Not sure who id rather be the vaginal exam volunteer or the prostate exam volunteer?? Hahha, i'll get back to my studies on that note.