SOAP note
The 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 (S), objective (O), assessment (A) and plan (P). The SOAP method was first introduced by Larry Weed, an American physician, researcher, educator and author, during the 1970s in the United States. Weed's experience as a medical researcher helped him formulate the SOAP structure as a problem-oriented tool to consistently guide patient assessment as a cognitive aid.
SOAP note components
Subjective (S)
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, both medical and social, Review of Systems (ROS) and Current Medications and Allergies. This subjective narrative provides context that assists the physician in further assessment and diagnostics.
Objective (O)
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 data that can be verified by objective observation: physical exam findings, imaging results and previous provider's documentation.
Assessment (A)
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 (P)
The fourth, and final, section of the notes is the plan of treatment determined by the physician. This usually includes a course of action(s) 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
The SOAP method for medical note taking is still the most common method in use today. In addition to the usability of the method, the legal requirements of medical charts follows the general sequence of the SOAP method. This format enhances the method's usability across all platforms.
The advent of EHRs and the varied formats of those in practice encourage following the traditional SOAP note method for charting. Despite the different interfaces, all clinicians can follow the SOAP logic while entering patient data. This consistent logic flow aids in developing frameworks that enhances interpret-ability across providers.
Criticism
The order of the SOAP format has been called into question. A study done on changing the order from SOAP to APSO (assessment, plan, subjective, objective) 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 prompting the need to provide the most urgent information regarding a patient concisely and upon initial view.
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 data from 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.
References
1. Lew V, Ghassemzadeh S. SOAP notes. 2018 [internet]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK482263/
2. Wright A, Sittig DF, McGowan J, Ash JS, Weed LL. Bringing science to medicine: an interview with Larry Weed, inventor of the problem-oriented medical record. 2014 [internet]. Available from: https://www.healthcareitnews.com/news/rethinking-progress-note
3. Pearce PF, Ferguson LA, George GS, Langford CA. The essential SOAP note in an EHR age. The Nurse Practitioner. 2016;41(2):29–36. doi:10.1097/01.NPR.0000476377.35114.d7.
Submitted by Summer Carrillo
