How SOAP Notes Paved the Way for Modern Medical Documentation

Interconnectivity isn’t as new a concept as some health IT vendors let on. Even though EHRs that easily share patient information between providers are revolutionizing health care, the idea of improving inter-physician communication has been around for decades. A perfect example? SOAP notes.

Today, the SOAP note – an acronym for Subjective, Objective, Assessment and Plan –  is the most common method of documentation used by providers to input notes into patients’ medical records. They allow providers to record and share information in a universal, systematic and easy to read format.

Many elements of modern health care are a byproduct of the SOAP note. EHR systems, a number of HHS’s Meaningful Use objectives, and specialists working off their mobile devices – are all, somehow, built upon the SOAP methodology.

In fact, SOAP notes are so prevalent among physicians that using an EHR equipped with SOAP note template creation is almost unquestionable. The best-designed EHRs combine form and narrative based functions to create note taking capabilities that allow you to rapidly drag and drop symptoms as well as input data manually.

Today, we look back at the history of the SOAP note and how it can be applied to modern practices.

The Story Behind SOAP
The SOAP note was first introduced into medicine by Dr. Lawrence Weed in the 1970’s, under the name Problem Oriented Medical Record (POMR).  At the time, there was no standardized process for medical documentation.

SOAP notes gave physicians structure and a way for practices to communicate with each other, a notion that is still transforming the industry. It was the initial users of SOAP notes who were able to retrieve patient records for a given medical problem the fastest – something EHRs do even better today.

Similar to how EHR software has improved the way providers find patient charts, standardized SOAP notes allowed providers to communicate with each other in clear and concise formats. In their own way, both have significantly enhanced the practice of medicine and improved health outcomes for millions of patients.

How To Use SOAP Notes
SOAP notes are broken down into the four components mentioned above, and they’re to be followed sequentially in order to complete a patient’s note.

Initially, the physician fills out the subjective portion, which includes any information received from the patient, such as history of illnesses, surgical history, current medications and allergies.

Then, the doctor moves on to the objective component by entering any vital signs and measurements, findings from physical examinations, abnormalities and results from previous laboratory and diagnostic tests.

Next, the assessment is where the doctor diagnosis the patient’s condition according to the medical history and objective data provided above.

Finally, the plan is where the health care provider will treat the patient’s concerns – such as lab orders, radiological work, referrals, procedures performed, medications given and education provided. This should address each item of the assessment and speak to what was discussed or advised with the patient, as well as scheduling for further review or follow-ups.

What Does a SOAP Note Look Like?
Below is an example of a SOAP note for a patient who has reported head pain after taking a serious fall.

(S)ubjective 25 year old pt presents with a head contusion after falling from a horse on to a heavy wooden fence, breaking the fence. Pt complains primarily of head pain, neck pain, right knee pain and some mild coccyx pain. There was a brief loss of consciousness observed by her brother and regaining of consciousness with repetitive questioning. Thereafter, she again lost consciousness for a short period of time. Pt has been slow to answer questions and has been noted to have repetitive questions since the accident.
(O)bjective Pt in no acute distress. Appears to be stable with C-collar and rigid backboard.HEENT:  Minimal tears in the occipital area; pupils: equal and reactive.EOMS:  Full.

EARS:  No blood.

NECK:  C-collar in place, with a tenderness over the mid C-spine bony area without obvious swelling or deformity. (C-collar left in place.)

CHEST:  Non-tender to compression. Equal breath sounds.

CVA:  Regular rhythm.

ABDOMEN:  Soft. Non-tender extremities.

NM:  Moves all fours well. There is mild tenderness on palpitation over the right patella but no instability, no limitation of

ROM. Cranial nerves II-VII intact. No meds. 

 

(A)ssessment Mild concussion.
(P)lan CT of the head after C-spine is clear. Home with head injury instructions. Recheck with private doctor in 12-days or return here PRN with any change in mental status.

Fairly straightforward, right? Well, simplicity is what Dr. Weed had in mind when he created this quick and efficient way to document patient encounters, which has segued into the modern medical documentation EHR vendors are working hard to perfect.

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