Resident+review+Soap+Note+-+example

**University** **of Colorado** **Family Medicine Residency Program** **__Subjective__**: contextual information about resident (i.e. where they came from, what their goals were upon entering residency, where they are emotionally/socially, etc.) // R1 at end of internship. Graduated from state medical school. Longstanding interest in FM based on importance of FP in her family’s life. Wants to return to hometown to practice. Recently married but stressed with her husband still living 100 miles away because he can’t find a job here. // **__Objective__**: data from blue folder (evaluation tools available and results), from conversations with preceptors, other faculty and advisee // Since last review has evals from medicine, peds, surger y//
 * Resident Review SOAP Note **
 * Resident: //Allison// Advisor: //Miller// Date: //4/27/06// **

· Rotation Evaluations: // high satisfactory, both med and peds remark on very complete w/u and detailed pt care. // · Precepting Feedback:// Clinic seems more difficult; can only handle 3-4 pts per session. Lost when devising a plan for a pt with more than one problem // · Rotation Evaluations: // Rated above average on every rotation // · In-training exam scores: // 65 % // · Rotation Evaluations: // No comments from rotations. Clinic preceptors say she seems unable to discuss any solution to improve her efficiency in clinic // · Rotation Evaluations: // Does well on rotations with patients // · Videotaped Sessions: // Connects with patients; very thorough; really listens to pt concerns // · Standardized Patients: //none since last review// · Rotation Evaluations: // No problems noted on rotations, but significant problems in clinic. When the staff tells her to hurry up, she becomes upset and often cries. Then the nurses are upset and the rest of the session goes badly // ·  Education Prescription Plan (EPP): //Has followed up well; she now looks up material on the inpt services. She has discussed with advisor the difficulties of being an intern and newly married.// · Rotation Evaluations: //No comment// //on rotation evals// · EMR skills: // Unknown, but doesn’t like dealing with the EMR //  **__Assessment__**: Novice (identifies/uses rules of thumb), Advanced Beginner (connects rules to reality), Competent (plans approach/execution and appreciates consequences), Proficient (uses evidence and streamlines routines), Expert (anticipates and uses intuition) // In inpatient situation, seems to be at an advanced beginner. But in clinic, she seems to be functioning at a novice level. // □ Below Expectations □ Meeting Expectations □ Exceeding Expectations // She is below expectations in clinic; she is meeting expectations on the inpt service. // **__Plan__**: FED (feedback, encouragement and direction) including successful methods and techniques unique to this resident (verbal, written, demonstration, self-directed): **1) ****Feedback (behavior specific, objective, useful)**  **2)  ****Encouragement** **3) ****Direction**  **4)  ****Date Resident FED based on this Resident Review:**
 * 1) Patient Care: **
 * 2) Medical Knowledge: **
 * 3) Practice-based Learning and Improvement: **
 * 4) Interpersonal and Communication Skills: **
 * 5) Professionalism: **
 * 6) Systems-based Practice: **
 * 1) Dreyfus level Compared to Practicing MD: **
 * 2) Competency level (compared to peers): **