Created in 1968, the subjective, objective, assessment, plan or SOAP ordering for organizing physician progress notes is now in the midst of a controversy. Perceptions about the efficacy of this standard format for organizing patient information have undergone a change with the advent of electronic health record (EHRs). Many clinicians point out that while the SOAP worked well when notes were made on paper, using this format is not feasible in the EHR age.
The order of the traditional progress note format is: Subjective – history; Objective – vital signs, physical exam and test results; Assessment – diagnosis and documentation of the thought process and decision making, and Plan – plan of treatment.
A study published in 2013 reported that the main concern with the use of the SOAP format in EHR was that it involved excessive clicking and scrolling to find the assessment and plan. This has led many physicians to switch from SOAP to APSO, where assessment and plan come before subjective and objective. An early adopter of the alternative to SOAP, the author of the 2013 study noted that putting the assessment and plan first was more practical as physicians usually go to the assessment page of paper charts first to see what previous visits or referring doctors may have found.
Today, physicians continue to be divided in their opinion about the progress note format in EHRs. This is what critics of SOAP have to say:
- In medical records viewed on a computer, history of present illness, past medical history, family, and social history, review of systems, and physical exam more space than available on the monitor.
- To find the assessment and plan, the physician has to scroll to areas that are not visible at first glance.
- This is aggravated by the fact that, in EMR notes, physicians end up documenting repeated information like past medical history and family history in great detail. In a dictated note, such information is stated very briefly.
- In electronic medical record templates that simply try to reproduce the end product of a dictated SOAP note, the result is a note in which key information can be found only by scrolling through two or three pages of data
On the other hand, in an article titled ‘Can APSO really displace SOAP’ published in the Medical Practice Insider, a supporter of the SOAP format noted that it’s “more about the order the notes are ultimately displayed than how they are recorded.” This physician calls APSO an “upside down methodology” that fails to meet quality care or compliance mandates. He points out that the current EHR templates result in truncated ‘Present Illness’ information, while medical history information is far more extensive in the traditional format and includes “the critical subjective elements of chief complaint, past medical history, social history, family history and review of systems.” This information needs to be documented, failing which it would result in problematic clinical care, preventing physicians from providing the level of care necessary for complex patients.
As the debate continues as to whether APSO can displace or replace SOAP, physicians can ensure accurate and timely documentation with EHR-integrated medical transcription services. In fact, professional medical transcription service companies provide customized EMR-friendly documentation of clinical notes, consultation records, imaging and lab reports, operative reports and discharge summaries – all of which are critical to medical decision making and continuing care.