SOAP note
SOAP note
SOAP note is one of the most widely used methods of documenting a medical encounter between a physician and a patient. The term SOAP is an acronym which stands for subjective, objective, assessment and plan. The SOAP method was first introduced by Larry Weed, an American physician, researcher, educator and author, in the 1970s in the United States. Through Weed's experience as a physician he formulated the SOAP structure to consistently guide patient assessment as a cognitive aid.
SOAP note components
Subjective The first set of notes pertain to the personal experiences, views or feelings of the patient. The narrative is categorized into 5 sections: Chief Complaint (CC), History of Present Illness (HPI), History, Review of Systems (ROS) and Current Medications and Allergies. This subjective narrative provides context that assists the physician in further assessment and diagnostics.
Objective The second set of notes refer to the objective data gathered from the patient during the appointment. This section will house quantitative findings such as: vital signs, laboratory data, diagnostic data as well as physical exam findings, imaging results and previous provider's documentation.
Assessment The third set of notes focus on the synthesis of the subjective and objective findings. The assessment is where the official problem, or diagnosis, is documented. It is common for providers to document differential diagnoses ranked from most to least applicable in addition to the primary diagnosis.
Plan The fourth, and final, section of the notes is the plan of treatment determined by the physician. This usually includes a course of action such as: testing, therapy, follow-up by primary care doctor or specialist, education and/or counseling. The plan portion is not only meant to guide the next step in patient care, however, to aid other providers when encountering the patient.
Current Use
Criticism
The order of the SOAP format has been called into question. A study done on changing the order from SOAP to APSO found overall improvement in speed of documentation, veracity of data and usability for patients with chronic disease. By shifting the first two sections to assessment and plan allows the succeeding physicians a more efficient way to acquaint themselves with the health status and plan of the patient. This is particularly important within electronic health records(EHR). EHRs are constrained by screen size and interfaces and therefore need to provide the most urgent information regarding a patient concisely.
The greatest criticism of the SOAP method is the inability to process updates of data over time. It is difficult for providers to browse through patient charts with several encounters and determine the efficacy of past treatment plans in a timely manner. A recommendation to the format in attempt to reconcile this issue is to amend the title SOAP with the acronym "e" referring to evaluation of treatment plans.
Sources https://www.ncbi.nlm.nih.gov/books/NBK482263/ https://www.healthcareitnews.com/news/rethinking-progress-note
