The veil is being lifted on documentation practices in healthcare. Whereas once large medical groups got away with monitoring their progress notes internally, big data is making it mandatory to write the perfect progress note each and every time. The standards for the perfect SOAP note are going high, especially as patients record more of their doctor visits.
Physicians have been writing SOAP notes for decades. It used to serve the purpose of documenting the care history of a patient. It has since evolved into a billing and legal practice.
The progress note these days holds a lot of information. It’s the cleaned-up version of the audio conversation between the doctor and the patient. It’s the filtered version and it has plenty of biases and isn’t always accurate.
If it’s not in the chart it didn’t happen!-the current state of medical documentation
The Anatomy of a SOAP Note
There is no consensus as to what makes for a high-quality SOAP note. There is no institution that would serve as the source of truth.
Many physicians end up in “documentation camps” because they got sued and were forced to remediate their heathenous practices. Or the medical board found them to be writing short notes which was discovered after a patient complaint.
There is a lot of risk in medicine and the SOAP note is the noose that hangs us. Even more so in telemedicine, where the note is all we have.
The perfect SOAP note should …
- follow a predictable grammar structure
- delineate subjective from objective
- be easy to reference
- use proper medical terminology
- should be as concise as possible
The subjective is the HPI and the Past Medical History which the patient provides. It should be written in the patient’s words whenever possible.
Physicians often confuse the way they “present” a patient in grand rounds with what they write in the SOAP note. Forget presenting the patient to your attendings – we’re past that.
In the subjective section of the perfect SOAP note, I want to summarize what the patient told me. I want to separate different chief complaints into different paragraphs.
Ideally, the pertinent positives are listed first, followed by the pertinent negatives.
Next, we can add the associated symptoms. Or, sometimes, it’s easiest to break out a more complex history into an ROS for a less-cluttered HPI.
If something a patient says could be misconstrued by someone else reviewing this chart or if what they are saying is out of the ordinary it should be put into quotation marks.
The objective is where the physical exam findings are included. Vitals and photos and lab results and imaging studies should also be documented here.
If a patient tells me they had a positive home pregnancy test or they were told their MRI should a labral tear, that goes in the Subjective. If I’m reviewing the MRI, as in, it’s an official report, I’ll include that in the Objective section.
This is the one section which most physicians, scribes, and professional coders can’t fully grasp.
This is the physician’s medical reasoning for what they think is going on. It’s not a summary of the case. It’s not just an ICD1X code. It’s part of the MDM to understand why the physician next ordered what they ordered or recommended what they recommended.
This can be written in paragraph form and though it’s often brief, it can be half a page long for a more complicated patient encounter, especially for specialists.
It should be written using medical terminology. This is important because it’ll prevent confusing effusion-swelling with edema-swelling, etc.
This otherwise healthy 21-year-old female has acute-onset bilateral wrist effusion with no systemic symptoms and no history of recent trauma to explain it. Her recent change in exercise routine likely isn’t the cause and since I cannot rule out autoimmune arthritis such as Rheumatoid Arthritis I will work this patient up further with close monitoring.
It’s a good habit to use the words “likely”, “unlikely”, “possible”, or “cannot rule out”, etc. These are used to convey to the reader what the various Differential Diagnoses were considered and why they aren’t considered.
I don’t need to mention in the Assessment section what tests I’m going to order and why. The Plan section can be used for that.
The Plan section is the continuation of the MDM. It’s not enough to list the medication which was prescribed.
The perfect progress note will have the full name of the medication, dosage, frequency, and route of administration. It will be followed by why it was ordered – as in, for what suspected diagnosis.
The Plan section needs to also include that we had a discussion with the patient regarding their options. That we explained to them the disease process and reviewed the side effects of the medication with them.
It’s 2021 and the Plan section needs to be longer and longer. And we should expect it to only get longer as time goes on. Everything from “patient agreed with management” to “all questions answered”.
Purposes of the Progress Note
1. Protect the Physician
The purpose of a progress note for me is to protect me against a bad outcome. No, it’s not to document the care history of the patient – that can be done with a few simple lines.
As a physician, it’s important that my progress note reflect the nature of the visit. It should indicate whether the patient was agreeable or perhaps doubted me and whether I thought the visit was straightforward versus complex.
If I discussed going to the ER with the patient or that their diagnosis isn’t clear from the current data, all of that should be reflected in the chart.
Defensive charting isn’t healthy, I know that. But I recall many examples where I wish I had charted more and many examples where my charting protected me.
2. Thinking Process for the Physician
I think better when I write out the note. Even if I’m not the one writing it (scribe), it helps for me to get my thoughts down on a screen and analyze the connection between CP and SOB. Often times I remember CHF and PE in my DDx when before I was only considering an MI.
This is the benefit for the physician who is writing their note. For the physician who follows up with the patient, reviewing the facts in the older progress note also helps spark ideas and DDx’s which may have otherwise been missed.
The perfect progress note shouldn’t be a 1-way dump onto a screen for an EMR. The data, as it’s displayed, helps the physician expand their DDx. This has been my argument for a smart EMR which is a topic for another day.
3. Document Care History
Our modern healthcare system has left the tracks and somehow it’s been decided that we should be spending less time with each patient and have more patient interactions.
We’ve indirectly agreed that we need “appointments” like the DMV and that our services should be rated the way you rate your late-night roach coach.
For this reason it’s likely that a patient will have multiple visits with multiple clinicians in multiple healthcare systems before they ever get a final diagnosis. That’s why the perfect progress note can tell a great story – it can carry the old history and document the care history of the patient happening live and into the future.
If the patient’s ESR is negative and Rheumatoid Factor is negative as well I will suggest that we consider plain film imaging of extremities and/or MRI of the hands and feet in order to evaluate this patient further for possible erosive arthritis.
4. Patient Data Collection
Healthcare is full of important data but we don’t have the right training in data science to make good use of it. I’m excited about the many health information technology degrees popping up to help bridge that gap.
In the meantime, we need to collect good data. Clean data. If I create such an indistinguishable summary of a UTI visit that it looks like a carbon copy of another patient I won’t be able to do much with this data.
In order for us physicians to get more support, we must do our part to make sure that the data we’re putting into the chart is a fair representation of what happened.
The argument I have against this is that all future patient visits will soon be transcribed. Whether we’re ready for this or not it’s the next wave of healthcare data that will require a major culture shift.
5. Capture Billing
Billing codes and reimbursement is getting more and more complicated. Sifting through a SOAP note and captured unbilled codes is big money. The perfect SOAP note will have everything in it from which the physicians and the healthcare system should fairly profit.
Some EMRs do a much better job of capturing data that can be used for billing. What we can do as physicians is to focus on the ideal patient-doctor relationship and just become more familiar with billing.
If an ROS was done but we didn’t capture it then it’s a loss for everyone involved.
Criteria for Writing the Perfect Progress Note
The perfect progress note will tell a story, be easy to read, be clinically accurate, and it should be a note you can be proud of.
I imagine one day sitting before a state medical board or a lawyer or judge and have my progress note up on a big-screen. I feel naked just thinking about this but that’s the reality of healthcare in the US.
All of us knew a resident who wrote the best notes. I don’t want my progress note to be that awesome but I want it to hold up to scrutiny.
If I prescribed a medication I want its name in my SOAP note. And I want to mention that I discussed the side effects with the patient. This documentation practice has the added effect of forcing me to be more thorough in my visits.
In the near future, all our patient-doctor conversations will be recorded. We need to get ready for this change now and I don’t think it’ll hurt us.
What Physicians Should Do
I need to unlearn how I have been documenting a visit over the past few years. The visit outline has to be more detailed and I need to write it for an audience of patients, other doctors, lawyers, and state medical board investigators.
Thinking out loud is a great way to get more down on the keyboard. All the parts of the visit which we figured out in our heads should be explained to the patient. When you explain it it’s much easier to write it out.
Review some “perfect” SOAP notes. They aren’t easy to find but they are out there. Once you read a few of these notes you’ll get a sense of how much detail to include.
What Medical Groups Should Do
Changing physician habits is hard. Scare tactics don’t work. And you won’t appeal to our administrative sides because we’ve learned to shy away from such individuals.
Repetition is key. The progress note committee should be made up of different physicians who are actively practicing. Good example notes displayed side by side next to more anemic notes is a good start.
Medical groups need to be more transparent when it comes to malpractice cases and discuss instances when the lack of documentation hurt a patient case.
The note needs a better anatomy than what we have now. A checklist is a good way for a physician to know whether they covered all aspects of a chart.
An interactive progress note with digital scribe technology is a great way to display the covered topics of the patient-doctor visit. Was the medication side effect reviewed? Did we ask if the patient had other questions? Did we educate the patient about driving while under the influence?
These live prompts are answered by the physician before closing the chart. If they were covered they can be automatically added to the chart, if not, it’ll serve as a repetition for the physician to ask about next time.