try soapnote

soapnote.org is a web site intended to help medical providers make and share clinical documentation templates and calculators.

You can read about using templates at the HOW TO page.

And, you can read about making templates at the 3 STEPS page.

You can browse by tag or category. You can also take a look at everything on the SITEMAP page.

Confused? There's a lot of options if you have questions:

1. There's a page with some tutorials at the DEMOS page.


2. There's a frequently asked questions page at the FAQ page.


3. There's a help forum waiting for you to ask questions at the HELP FORUM page.

And, there's important information including terms and conditions at the ABOUT US page.

You can always email me at mark@soapnote.org if you have any questions!

June Journal Club Announcement - June 8th

June Journal Club

Date:  Tuesday, June 8

Time: 6 PM at Courtyard by Marriott - Saints on Second Restaurant.  Food orders at 6:15 PM

Topic:  Treatment of Diabetes Mellitus

Article:  "Choosing among the incretin agents and why it matters" in the Journal of Family Practice. The article is at http://bit.ly/9zvg5b

Also, an additional resource (for extra credit):  Annals of Internal Medicine "in the clinic: Type 2 Diabetes". The article is at http://bit.ly/blP4IO and this will provide some background/perspective to the discussion.

Discussion will be led by Dr. Shawn McManus (PGY-2 Resident) with Dr. John Bachman as the consultant supervising the discussion.

RSVP with Tammy!

June Journal Club Announcement

Hi Tammy,
Here's the announcement for June Journal Club:

June Journal Club
Date:  Tuesday, June 8
Time: 6 PM at Courtyard by Marriott - Saints on Second Restaurant.  Food orders at 6:15 PM
Topic:  Treatment of Diabetes Mellitus
Article:  "Choosing among the incretin agents and why it matters" in the Journal of Family Practice. The article is at http://bit.ly/9zvg5b

Also, an additional resource (for extra credit):  Annals of Internal Medicine "in the clinic: Type 2 Diabetes". The article is at http://bit.ly/blP4IO and this will provide some background/perspective to the discussion.

RSVP with Tammy!

Nursing home quality improvement project

Stop using the word antipsychotropic.

Begin using the metric system.

journal club announcement

Hi Tammy,

 

Here's the announcement for next week's journal club.

 

MARCH JOURNAL CLUB DETAILS:
Who:  Dr. Ana Caro.  With Dr. Tara Kaufman faculty supervisor.
When:  Tuesday, April 13 at 6:00 PM
Where:  Victoria's private room
RSVP to Tammy for attendance.

 

The article is "The role of calcium score and CT angiography in the medical management of patients with normal myocardial perfusion imaging".  It may be viewed on the web here:  http://bit.ly/aYy04N

 

Take care,

Mark

ABFM Certification Summer Exam Dates 2010

Dates: Certification and Recertification

Certification, Recertification and Sports Medicine Exams			2010
SUMMER EXAM 2010
Online Application Available	January 28
1st Deadline to Submit the Online Application ($1,250; No Late Fee Assessed)	February 28
2nd Deadline to Submit the Online Application ($1, 400)	March 31
3rd Deadline to Submit the Online Application ($1, 550)	April 30
Deadline for Priority Seating in Test Center Selection	May 12
4th Deadline to Submit the Online Application ($1, 700)	June 1
Deadline to Withdraw from the Examination without Cancellation fee	30 Days Prior to Scheduled Exam
Final Deadline to Submit the Online Application ($1,850)	June 15
Deadline to Submit Special Testing Accommodations Documentation	June 15
Deadline to Clear all Deficiencies	June 24
Deadline to Make Official Name Change with the ABFM for Examination	June 24
All Family Medicine Residency Training Must Be Completed (Primary Certification Candidates only)	June 30
Deadline to Provide ABFM Residency Training Completion Letter (Primary Certification Candidates only)	June 30
All Sports Medicine Fellowship Training Must Be Completed (Sports Certification Candidates only)	July 31
Deadline to Provide Sports Medicine Fellowship Training Completion Letter (Sports Certification Candidates only)	July 31
Deadline to Select Testing Date/Location	July 1
Deadline to Change Testing Date/Location	48 hours prior to scheduled exam
Deadline to Withdraw from Examination	5 days prior to scheduled exam
Examination Dates	July 12, 13, 14, 15, 17, 19, 20, 21, 22, 23, 24

Physician Rotation at MDH

 

The close collaboration between the Minnesota health care community and the Minnesota Department Health has been critical to the many successes in public health that Minnesota has experienced. In order to expand and improve this close relationship, MDH offers a two-day rotation for physicians-in-training with the goal of improving knowledge and communication between the health care community and MDH.  It is about 10 hours split between a Monday and Friday and offered about every 4 weeks. Upcoming dates for this academic year are below.

 

Content experts predominantly in the Infectious Disease Section and the Public Health Laboratory cover topics on an individual or small group basis including foodborne disease, zoonoses, vector-borne disease, infection prevention and control, refugee health, tuberculosis, immunizations, HIV/STD’s, laboratory and molecular epidemiology, and hot topics such as H1N1 Novel influenza among others.

 

Content is targeted toward residents but interested medical students would also be considered. If you have someone interested or have further questions about the rotation please let me know.

 

Please feel free to forward this to others within your program as well as others outside of your program who might be interested.

 

Minnesota Department of Health
Infectious Disease Epidemiology Prevention and Control
 

Springboard message [asthma and beta blockers]

Today's Springboard covers long acting beta agonists and avoiding their unnecessary use in asthmatics.
http://content.nejm.org/cgi/content/full/362/13/1169

Specific Label Changes for Long-Acting Beta-Agonists (LABAs).
1. Contraindicate the use of LABAs for asthma in patients of all ages without concomitant use of an asthma-controller medication such as an inhaled corticosteroid.

2. Stop use of the LABA, if possible, once asthma control is achieved and maintain the use of an asthma-controller medication, such as an inhaled corticosteroid.

3. Recommend against LABA use in patients whose asthma is adequately controlled with a low- or medium-dose inhaled corticosteroid.

4. Recommend that a fixed-dose combination product containing a LABA and an inhaled corticosteroid be used to ensure compliance with concomitant therapy in pediatric and adolescent patients who require the addition of a LABA to an inhaled corticosteroid.|

As we begin to increase our involvement in medical school education, I would like to make you aware of a program that helps people initiate programs

http://www.stfm.org/conferences/mseinstitute/index.cfm

Have a good week
John

Free Access to BMJ Clinical Evidence Web Site

Here is information regarding free access to BMJ's excellent Clinical Evidence resource.

As of this posting, the general procedure is going to this web page and entering "United Health Foundation 2008" in the password field.

And from what I can tell, this is one of the few resources that isn't available via the Mayo library.

Springboard message from Dr. John Bachman

http://hbr.org/fixing-health-care

Last week with the Health Care Reform bill passed and Dr. Terry McGeeney's presentation, I thought we should have three articles from Harvard Business Review's latest issue.

The first has great graphics:  http://hbr.org/2010/04/what-drives-high-health-care-costs-and-how-to-fight-back/ar/1

The next two are very helpful in setting the stage for change.

The first turning doctors into leaders http://hbr.org/2010/04/turning-doctors-into-leaders/ar/1

and the second fixing health care http://hbr.org/2010/04/fixing-health-care-on-the-front-lines/ar/1

Great stuff for forward thinking people.

John

MAFP presentation

Here's the link to the presentation on a web application for clinical documentation
http://docs.google.com/present/view?id=dcz8t5wb_1172hpfpdbg4


Here's the link for the comment form and to receive notification when soapnote.org is released:  http://bit.ly/dvypLF

April 2010 Journal Club

WHEN: TUESDAY, APRIL 13, 2010 AT 6 PM.


WHO: Dr. Ana Caro will be leading the discussion. Dr. Tara Kaufman is the staff facilitator.

WHERE: TBA

ARTICLE FOR DISCUSSION: The role of calcium score and CT angiography in the medical management of patients with normal myocardial perfusion imaging  HERE

RSVP with Tammy Younge so we can figure out logistics.

About Journal Club

Journal club is a monthly meeting the second Tuesday every month. It intends to focus on the evidence that supports the care we provide. Usually we'll be reviewing a single journal article.

To prepare, we ask that you read the article.

Most of all it's supposed to be relevant and interesting.

Email me if you have ideas for articles for discussion and/or you'd like to facilitate a discussion.

From N. Rasmussen--Article of interest re: Impact of apathy on glycemic control

To My Colleagues,
Attached is the link to a 2008 article published in Diabetes Research and Clinical Practice on the impact of apathy on glycemic control in diabetes. Traditionally, apathy has been viewed as part and parcel of depression. However, more recently in the psychology and psychiatry community, apathy is viewed by many as an independent or at least semi-independent condition separate from clinical depression. The attached study found that over half of the diabetic sample had clinically significant apathy without a diagnosis of depression, and, furthermore, the apathy was correlated with poorer diabetic outcomes compared to the non-apathetic patients regarding HbA1c and self-care.
Two issues seem to be relevant to the family physician regarding the apathy literature and diabetes.  First, virtually all depression tests mingle apathy items with other depressive symptoms and thus it is not always apparent that apathy type symptoms constitute the predominant cluster in a diagnosis of depression.  Second, this has pharmacologic treatment implications – prescribing an SSRI may only exacerbate the apathy when perhaps, based on what I read, a dopamine agent may be more effective. The obvious aim of course would be to decrease the apathy and thereby improve patient self-care and diabetic control. 

HERE is the article

Keloids

A response to this post.
Can your really achieve a good clinical/cosmetic response in keloids with OS/P?. Does size or location matter? Any experiences?
Mirko.
-----------------------------
Mirko,
I looked.  A review of the literature done 2 years ago showed evidence for cryo or cryo + intralesional steroids poor quality evidence. .   (J Plast Reconstr Aesthet Surg. 2008;61(1):4-17. Epub 2007 Jul 19.)  One small n study since then that was prospective and randomized showed the combination better than cryo alone.  J Cosmet Dermatol. 2007 Dec;6(4):258-61. 
My preference has been to inject intralesional steroids in small amounts of 0.1 to 0.2 ml of 1:1 triam 40 mg/ml and Bupivacaine or Xylo with multiple injection points using a 27-30 g needle on an every 2-3 week basis until desired result.  Anecdotally this works very well.  As a result of the above evidence, I'll now try a pre-cryo with 10-15 seconds of freeze prior to injecting.  FYI, I am now using a Jet injector (Madajet) for intralesional steroid placement in the Procedure Clinic - takes seconds for multiple injections and blows it in nicely intralesionally with less pain. 
I have excised large keloids previously.  Post operative steroid into wound margins beginning at suture removal 1-2 weeks after excision with tight wrapping for 18+ hours per day probably/may/anecdotally reduces recurrence.  A low tension closure is key (since as you've seen on some people with excisions with higher tension closures which weren't undermined, they get keloids whether they are prone to them or not).  Topical steroids (high potency), imiquimod and tacrolimus, and a host of other immune modulators have also been studied to inhibit alpha-2-macroglobulin which is a collagenase inhibitor and thus increase collegenase activity (blah blah technical blah blah).  Cheap works, so stick with steroids until someone proves that one of these others is clearly superior.
Steve

Springboard message from Dr. Bachman

This is the presentation from Terry McGinney, M.D., M.B.A.  HERE
I would encourage residents to sign up for the Delta Exchange:
http://www.transformed.com/Delta-Exchange/index.cfm  
It is free for our residents. Residents should also check out the site for preparing you for practice (P4) :
http://www.transformed.com/p4.cfm
At dinner with Terry McGinney at our home, there was discussion of the inadequacy of teaching in this country for simple procedures.  One of our residents pointed out that they were uncertain of wart cryotherapy and how long to hold the freeze.
http://www.aafp.org/afp/2004/0515/p2365.html  is an article that would be useful  
The freeze times are HERE.

Springboard Club from Dr. Bachman

Autism is something we are screening for on a regular basis This article is useful to review the topic HERE  This table shows the team members to help in the case HERE
As you read this remember it was written by a third year resident.  We have people just as talented in our group
Teaching  As we move forward with the transformation of family medicine I think this article showed an excellent project involving quality improvement with a preseptorship in offices
HERE

More than 1,000 medical students have successfully completed projects in Nebraska communities since the inception of the program. UNCOM student projects have won national awards at a variety of medical education conferences.2 Sample project instructions, descriptions, timelines, examples of student write-ups, and other pertinent documents can be obtained by contacting the author at ppaulman@unmc.edu.

Conclusion

The UNCOM Clinical Quality Improvement Project has been a successful collaboration between the College of Medicine, community family physician preceptors, and the Nebraska Academy of Family Physicians.

Springboard message Dr. Bachman

The medical literature this week went south with nothing really outstanding….  so I chose this click image (above).
The graph talks about retention of information If you chat with a patient and just talk, if you show pictures, or if you combine both.  If you look at the figure it will make a big difference in how you present to your patients as well as with your colleagues… Visual and Verbal together are the way to go… Pull out a piece of paper and draw for patients!   .I have included this web link http://www.osha.gov/doc/outreachtraining/htmlfiles/traintec.html  
*****************************************************************************
For young leaders who would like to meet in Cancun!
Attention emerging leaders in Family Medicine:
Are you interested in attending the World Wonca Conference in Cancun, Mexico in May 2010? Would you like to learn more about global family medicine while working with other national colleges and Wonca regions? (www.wonca2010cancun.com)
Leaders of the AAFP and the AAFP Foundation have made available travel grants of $1,000 for family medicine residents, new physicians (7 years or less since residency graduation) and medical students to attend this conference. The World Conference will be held from 19-23 May 2010. There will be at least 5 travel grants available; more grants may be available based on funding.
To apply:
Please submit by 1 April 2010
(1) a letter of interest, no longer than 1 page, that indicates why you want to attend.
(2) a resume or abbreviated CV of no longer than 1 page.
(3) a letter of recommendation from your residency program director, department chair, or other knowledgeable faculty/colleague.
Submit your information to
MAIL:
AAFP Foundation
Attn: Phyllis Naragon
11400 Tomahawk Creek Parkway
Leawood, KS 66211
FAX:
913.906.6095
EMAIL as PDF:
pnaragon@aafp.org
Ashley DeVilbiss Bieck, MPA
Student Interest Manager
American Academy of Family Physicians
11400 Tomahawk Creek Pkwy
Leawood, KS 66211
913-906-6000 x6722
913-906-6091, fax
adevilbi@aafp.org

Springboard message from Dr. Bachman

Recently there was a discussion regarding the role of family physicians in using methotrexate in rheumatoid arthritis. The conversation was whether family doctors should start methotrexate treatment without referral vs. referring patients to a rheumatologist because of legal consideration. Whenever disagreement over a topic is brought up it can become a learning issue.

Methotrexate for family physicians is 10 years old, but remains an excellent review with summaries of initiation and follow-up  http://www.aafp.org/afp/20001001/1607.html

Methotrexate concentrates in the kidneys, gallbladder, and spleen, as well as in the liver. Renal excretion eliminates 60 to 95 percent of a dose. Tubular secretion, reabsorption and glomerular filtration are all involved in the renal elimination of methotrexate. Therefore, methotrexate is contraindicated in any patient with a creatinine clearance of less than 50 mL per minute.

The UK uses shared care agreements with doctors who initiate the treatment being legally liable http://www.lmsg.nhs.uk/SharedCare/pdfdocs/MethotrexateSCAv2_1_200806.pdf

American Family Physician editorial talks of early referral to rheumatologist
http://www.ncbi.nlm.nih.gov/pubmed/16190501?dopt=Abstract

American College of Rheumatology 2008 recommendations states physician although in references talks about referring to a rheumatogist in other literature in the first three months of RA

http://www3.interscience.wiley.com/cgi-bin/fulltext/119635887/HTMLSTART?CRETRY=1&SRETRY=0

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2689523/?tool=pubmed Shows recomendatons for methotrexate and variation among rheumatologist

Law suits were certainly an issue. The ones I found were when doctors just gave the wrong treatments.  ie. In the treatment of rheumatoid arthritis and psoriasis there are given MTX doses ... she had been prescribed by her family doctor 20 mg/day MTX for 8 days. This caused the patient to die

So be careful and make sure when you see methotrexate on the list that you note this is one dangerous medication.

TEACHING
We all know about STFM   Here is another organization that gets people out of their boxes in teaching students.
http://www.iamse.org/   Check out the social networking issues

Springboard club (from Dr. Bachman)

Rotator cuff tear; link to see pictures http://content.nejm.org/cgi/content/full/358/20/2138   I thought this picture was useful  pull it up when you are checking someone!



MEETINGS
Mayo traditionally has a session at the practice improvement meeting  If you have a project or effort that would take 15 minutes to present let Kurt Angstman know and we will submit it as part of
A Mayo seminar.  People who have done this include Kurt, John Wilkinson, Steve Adamson, Tom Harmon, Vic Yapunuvich. The place is packed  Of course you can go it alone but I guarantee you will get in if you join this meeting
Conference on Practice Improvement: Assembling the Patient-centered Team
Conference Location: San Antonio, Texas
Conference Dates: December 2-5, 2010
TEACHING
http://www.stfm.org/documents/0109TeachPhy.pdf  Check out the last page on the videos available  I will see if we can get our department to get this for all of us who teach 
GRANT APPLICATION
Pfizer/American Academy of Family Physicians Foundation Visiting Professorship Program in Family Medicine
Grantor:American Academy of Family Physicians Foundation/Pfizer
Region:All Regions
Closes:03/19/2010
Maximum:$7,500
Pfizer/American Academy of Family Physicians Foundation Visiting Professorship Program in Family Medicine
Host a Prominent Physician-Scientist On Us

Apply to receive three days of teaching and interaction during the 2010-2011 academic year at your program or school. Six institutions will be awarded $7,500 each to invite a prominent physician-scientist of their choosing. The guest faculty may give lectures, as well as participate in rounds, seminars and conferences.

Awards are intended to cover the visiting professor’s honorarium, travel expenses and other direct expenses incurred by the host institution in conducting program activities. Amounts allotted for each item are at the discretion of the host institution.
Interested in applying in 2010?
Eligibility
Family Medicine departments within a U.S. medical school or any accredited Family Medicine residency program may apply. Applications from community-based programs are encouraged.

Grant Rules
* Each hospital may submit only one application.
* Submissions must originate from the Chair of the Family Medicine Department or the Residency Director.
* This program will fund just one visit per year per visiting professor.
* A proposed Pfizer Visiting Professor should accept only one nomination per year. Candidates are required to verify that they have not accepted more than one nomination.
* Pfizer Visiting Professorships must consist of three full days of Pfizer-supported professional proceedings. Visits are not to be conducted as an adjunct to other planned meetings or events.
* A member of the Visiting Professorship Academic Advisory Board may not act as a Visiting Professor during his or her tenure on the board. In addition, the home institute of a member of the Academic Advisory Board may not host a Visiting Professor during the board member's tenure.

Application materials for 2010 are available below. All materials are due by March 19, 2010.

If you have questions:

Contact Perry A. Pugno, MD, MPH, CPE, AAFP Medical Education Director at (800)274-2237, Ext. 6700, or Susie Morantz, AAFP Foundation Program Manager at (800)274-2237, Ext 4470
American Academy of Family Physicians Foundation
11400 Tomahawk Creek Parkway, Suite 440
Leawood, KS 66211-2672

Toll free: (800) 274-2237
Phone: (913) 906-6000
Fax: (913) 906-6095
Link:http://www.aafpfoundation.org/online/foundation/home/programs/education/professorshipapp.html
Categories:Academic Medicine, Continuing Medical Education, Educational Exchange, Family Medicine, Medical Schools, Visiting Professorships
John

Springboard Case from Dr. Bachman

The Mayo Proceedings had an article on pearls on thromboembolism. It also discussed using cases to present a review. The article has a nice style and makes some excellent points http://mayoclinicproceedings.com/content/84/12/1120.full  Those wishing to plan presentations nationally might look at the format

"At the 2001 annual conference of the American College of Physicians, a new teaching format to aid physician learning, Clinical Pearls, was introduced. Clinical Pearls is designed with the 3 qualities of physician-learners in mind. First, we physicians enjoy learning from cases. Second, we like concise, practical points that we can use in our practice. Finally, we take pleasure in problem solving.

In the Clinical Pearls format, speakers present a number of short cases in their specialty to a general internal medicine audience. Each case is followed by a multiple-choice question answered live by attendees using an audience response system. The answer distribution is shown to attendees. The correct answer is then displayed and the speaker discusses teaching points, clarifying why one answer is most appropriate. Each case presentation ends with a Clinical Pearl, defined as a practical teaching point that is supported by the literature but generally not well known to most internists."

Clinical Pearls is currently one of the most popular sessions at the American College of Physicians meeting
*********
The quality and safety forum was awesome. Don Berwick rocks  If you have never heard him this is a link to an excerpt of the presentation http://www.ihi.org/IHI/Programs/ConferencesAndSeminars/21stAnnualNationalForumonQualityImprovementinHealthCare.htm open the video clip it lasts about ten minutes

John