The SOAP Format for the Electronic Health Record

A medical record is a systematic documentation of a patient’s medical history and care. It usually contains the patient's protected health information (PHI) which includes identification information, health history, medical examination findings, and billing information. A typical medical record includes:

• Patient demographics
• Financial information
• Consent and authorization forms
• Treatment history
• Progress notes
• Physician's orders and prescriptions
• Consults
• Lab reports
• Radiology reports
• Nursing notes
• Medication list
• HIPAA Notice of Privacy Practices

The part of the medical record that uses the S.O.A.P format is the Progress notes section. S.O.A.P stands for Subjective, Objective, Assessment, Plan. The S.O.A.P format can still be used with the electronic health record just as it is used with traditional medical records.

Subjective notes pertain to the patient's ideas and feelings about how he or she sees the state of their health or treatment plan. This information should is documented based on the patient's responses to questions regarding treatment plans or current illnesses.

Subjective information includes:

• Past medical history
• History of present illness
• Review of symptoms
• Social history
• Family history

Objective notes pertain to the patient's vital signs, all components of the physical examination, and results of labs, X-rays, and other tests performed during the patient visit.

Objective information includes:

• Temperature, blood pressure, pulse, and respiration
• General appearance
• Internal organs, extremities, and musculoskeletal conditions
• Neurologic and psychiatric conditions
• Other information based on specialty

Assessment notes consolidate subjective and objective information together that results in the patient's health status, lifestyle, or diagnosis. The assessment includes an overview of the patient's progress since the last visit from the clinician's perspective.

Assessment information includes:

• Main symptoms and diagnosis
• Patient's progress
• Differential diagnosis
• Basic description of the patient and condition presented

Plan notes pertain to the course of action as a result of the assessment notes. The plan notes include whatever the physician plans to do or instruct the patient to do in order to treat the patient or address their concerns. This would include documentation of the physician's orders for a variety of services provided to the patient.

Plan information includes:

• Lab testing
• Radiology services
• Procedures
• Referral information
• Prescriptions or OTC medications
• Patient Education
• Other testing

There are many reasons why medical errors occur in the medical office. Most practices have a system or should have a system for preventing errors from occurring but poor communication is the number 1 reason that medical errors occur when a system is in place. Medical office staff, nurses, and physicians need to understand the importance of documentation which is the best way to communicate patient events.

Documentation not only includes symptoms, diagnosis, care, treatment, and medication but also problems and risks to health and safety information can all be effective in preventing medical errors. Remember to document prior mistakes and even the patient's concerns as well. Not all errors are avoidable but when information is documented accurately, health care professionals are able to identify and correct mistakes before an adverse medical event occurs.

Incomplete or inaccurate patient records and communication breakdowns can have serious consequences for the medical office and its patients. One vital piece of information not communicated can have disastrous results. Although some mishaps are unavoidable, effective communication can result in better outcomes for patients and the overall success of the medical office.