Forward-looking progress notes | Neurosurgery Basics

Forward-looking progress notes

D.D.A.V.P. your S.O.A.P.

Making rounds on hospitalized patients can be easy. We’re good at sizing up a patient’s condition, moving from the subjective report of their progress to the objective findings of vital signs and physical exam, lab results and radiographic images. This is the S.O. and A. of the S.O.A.P. note.

More difficult, however, is anticipating the patient’s future needs and answering the question, “What’s next?” This is the P. of the S.O.A.P. note. We should look ahead to the next milestones the patient needs to achieve. The ultimate milestone is discharge from the hospital.

So for every patient, you should ask, “What does this patient need to make progress toward discharge?” Here’s a mnemonic I find helpful: DDAVP

D: Drains, and all lines, including Foley and wound drains, IV fluids and arterial lines. Have the Foley removed as soon as the patient can void with minimal assistance. Heplock the INT when the patient is tolerating a diet.

D: Diet, advance the diet as tolerated. For stroke patients, a swallowing study may be useful. Diabetics will need a diabetic diet.

A: Activity, which should be advanced according to the patient’s ability. When you order PT, remember the therapist cannot walk the patient unless your activity order says out of bed!

V: Vital signs. A critical care patient may need hourly vital signs and neuro checks. As they improve, you can extend the interval between checks. This may also mean moving from ICU to a regular room.

P: PO medications. Your patient may need IV medications upon admission. As they make progress, convert them to the oral route, including anticonvulsants, muscle relaxants, analgesics and others.

All these steps, DDAVP, will help your patient make progress toward discharge. Include these in the P. of your S.O.A.P. note. Every patient encounter should include the steps that will move them toward the exit!