The shift to electronic health records (EHR) has brought about some resistance and fuss from physicians and practices, but at the core of this innovation are the goals of data security, and simplicity but effectiveness of patient information entry and its retrieval. The need for this, though, was felt decades ago.
EHRs following the HIPAA best practices rule by encryption, and efficient tracking can be extremely secure. Their straightforwardness and comprehensiveness in describing the patient’s condition are the other major benefits. Its goals seem to have had a lot of influence from SOAP (Subjective, Objective, Assessment and Plan) notes.
More about SOAP Documentation
SOAP notes were conceived out of a need for greater convenience and simplicity. It was introduced in the 1970s by Dr. Lawrence Weed at a time when medical documentation did not have a standardized process. Back then, Dr. Weed called it Problem Oriented Medical Record (POMR).
SOAP notes provided a definite structure for physicians and helped practices communicate better. This is still the basic concept behind the transformation of the industry. Doctors who began using SOAP notes could retrieve patient records faster; and this is one area EHRs excel in.
Quite like the way EHR software has helped providers find patient charts in an easier manner, SOAP notes did allow providers to communicate clearly and in a concise format. And since their they have played their part in improving health outcomes for many patients.
The SOAP Procedure
SOAP notes are, as the expansion of the abbreviation suggests, broken down into subjective, objective, assessment, and plan sections. These components are to be followed in their order:
- The physician first fills out the subjective element t basically deals with the information the patient directly gives. It could include symptoms felt by the patient, the medications he is under if any, the allergies he has to any drug, his surgical and medical history, etc.
- This would be followed by the objective component which would include vital signs, physical examination findings, previous diagnostic and laboratory tests, any abnormalities noted, etc.
- Then comes the assessment stage where the doctor conducts his diagnosis of the condition of the patient based on the aforementioned objective data and medical history.
- The final plan stage covers the actual treatment of the patient’s concerns including procedures carried out, radiological work conducted, lab orders referrals and medications and advice given. Scheduling for follow-ups or further reviews is also included.
Simple and quick but efficient documentation of patient encounters, which modern electronic health records hope to achieve, could be said to have its origin in what Dr. Weed created. A quick glance reveals just how simple the SOAP notes are.