What type of note taking method describes how patients treatment has changed?

In a previous post, we reviewed the necessity of basic best practices for SOAP notes including legibility, identification, and dated chart entries. In this post, we review the proper structure and contents of a SOAP note.

The acronym SOAP stands for Subjective, Objective, Assessment, and Plan. Each category is described below:

S = Subjective or symptoms and reflects the history and interval history of the condition. The patient’s presenting complaints should be described in some detail in the notes of each and every office visit. Using the patient’s own words is best. Routine use of one-word entries or short phrases such as “better”, “same”, “worse”, “headache”, “back pain” is usually not sufficient. In follow-up notes, “S” is a reiteration of the chief complaints elicited during the initial evaluation of the patient. The complaints should reflect change over time. The patient’s responses to the previous treatment, resumption of daily or occupational activities, intervening injuries, and exacerbations are also noted in “S.”

“S” should also describe improvement in the patient’s activities and physical capacities in the interim since the last treatment. Also included in this section are explanations for any hiatus in treatment and the patient’s compliance with recommended home care.

O = Objective or observations. This section includes inspection (e.g., “patient still walks with antalgic gait”) as well as a more formalized reevaluations such ranges of motion, provocative tests, specialized tests (fixations, tongue, pulse, BP, labs). The extent of the reevaluation at each office visit is determined by the information gathered in “S” together with the original positive clinical findings as well as changes in “O” at previous office visits. Usually only the critical indictors need be repeated. Findings should be qualified and quantified in order to be able to ascertain progress/response to care over time. Indicators for treatment should always be identified in order to document necessity of the treatment provided and described in “Plan” section of the note, for example motion palpation findings, stagnation of blood and chi, or abnormal lab values.

A = Assessment. Initially this is the diagnostic impression or working diagnosis and is based the “S” and “O” components of SOAP. On follow-up visits the “A” should reflect changes in “S” and “O” as a response to time, treatment, and other interim events (e.g., “Cervical strain, resolving” or “exacerbation of right sacroiliac pain”). “A” should be continually updated to be an accurate portrayal of the patient’s present condition. Other components of “A” may include the following where appropriate: patient risk factors or other health concerns, review of medications, laboratory or procedure results, and outside consultation reports.

P = Plan or Procedure. The initial plan for treatment should be stated in “P” section of the patient’s first visit. A complete treatment plan includes treatment frequency, duration, procedures, expected outcomes and goals of treatment. An initial treatment plan may be for an initial trial of treatment over a short interval with a re-assessment and further treatment planning at that later time.

On each follow-up visit, “P” should indicate modalities and procedures performed that day, continuation or changes in the overall treatment plan. “P” should also describe what the patient is to do between office visits, what the expected course of treatment is, what further tests might be ordered (e.g., “Obtain cervical MRI if upper extremity paresthesia persists”), and the disposition of the case (discharge, referral, etc.). It is also appropriate to include in this section any comments with respect to the patient’s compliance.

Ineffective communication is one of “the most common attributable causes of sentinel events,” according to an article in the Journal of Patient Safety. Given these stark consequences, the ability to convey medical information accurately, clearly and succinctly is a key skill all clinicians in training should strive to master.

In modern clinical practice, doctors share medical information primarily via oral presentations and written progress notes, which include histories, physicals and SOAP notes. SOAP—or subjective, objective, assessment and plan—notes allow clinicians to document continuing patient encounters in a structured way.

Exactly what is a SOAP note? Here’s an overview of how to write progress notes.

Subjective

Begin your SOAP note by documenting the information you collect directly from your patient; avoid injecting your own assessments and interpretations. Include the following:

1. The patient’s chief complaint. This is what brought the patient to the hospital or clinic, in their own words.

2. The history of the patient’s present illness, as reported by the patient. To standardize your reporting across notes, include information using the acronym OPQRST:

• The onset of the patient’s symptoms.
• Any palliating or provoking factors.
• The quality of the patient’s symptoms.
• The region of the body affected and (if the symptom is pain) if there is any radiation.
• The severity of the patient’s symptoms and whether or not there are any other associated symptoms.
• The time course of the patient’s symptoms.

3. Pertinent medical history, including the patient’s:

• Past medical and surgical history.
• Family history.
• Social history.

4. A current list of the patient’s medications, including the doses and frequency of administration.

Objective

The objective section of your SOAP note should, unsurprisingly, comprise objective information you collect from the patient encounter.

1. Start with the patient’s vital signs. Be sure to record the patient’s temperature, heart rate, blood pressure, respiratory rate and oxygen saturation.

2. Transition to your physical exam. Begin with a general impression of the patient, followed by the results of your head, ears, eyes, nose and throat; respiratory; cardiac; abdominal; extremity; and neurological exams. Additionally, include the results of any other relevant exams you’ve performed.

3. Report the results of any other diagnostics that have been performed, such as:

• Laboratory tests, including basic metabolic panels, complete blood counts and liver function tests.
• Imaging, including X-rays, computed tomography scans and ultrasounds.
• Any other relevant diagnostic information, including electrocardiograms.

Assessment

After you’ve completed the subjective and objective sections of your note, report your assessment.

1. Craft a one- to two-sentence summary that includes the patient’s age, relevant medical history, major diagnosis and clinical stability. For example: “Ms. K is an 85-year-old woman with a past medical history of multiple urinary tract infections who presented to the emergency room with dysuria, fatigue and a fever secondary to a new urinary tract infection. She is now clinically stable and has transitioned from intravenous to oral antibiotics.” If the patient has multiple major diagnoses, these should all be mentioned in your summary statement.

2. If your patient is experiencing any new symptoms, be sure to include a differential diagnosis as well. Aim to include at least two or three possible diagnoses.

Plan

Complete your SOAP note with your plan.

1. Create a list of all of the patient’s medical problems. Your problem list should be ordered by acuity.

2. Propose a plan to manage each problem you’ve identified. For example, if you’re in the midst of treating a bacterial infection, indicate that you plan to continue antibiotics.

3. If you’re taking care of an inpatient, be sure also to note their deep vein thrombosis prophylaxis, code status and disposition.

As with any skill, practice makes perfect. Try to view SOAP notes as learning opportunities, and with enough effort and time, you’ll become proficient in drafting these vital medical communications.

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