Once upon a time, I wrote SOAP notes. Most clinicians remember what these were. These were notes written to document a patient encounter, be it in the office or in the hospital. It was divided into four sections:
Subjective: What did the patient say?
Objective: Vital signs, physical exam findings, labs results, imaging studies;
Assessment: What the clinician thinks is going on with the patient, alternative diagnoses; and
Plan: What is to be done to either clarify the clinical situation or help the patient.
I wrote my SOAP notes with a fountain pen. Most clinicians think this is weird. (Kids, on the other hand, tend to think that this is pretty neat, affording me the opportunity to introduce the concept of capillary action). My notes had the date and each letter of SOAP underlined with two short strokes. The penmanship was relatively neat, but the note was difficult to decipher owing to the shorthand.
11/29/17
S – Pt. is a 4 yo male w/ 3d ho cough/runny nose. No F/V/D.
The process of handwriting a progress note was an intimate experience. Personal details from the history, coupled with sensitive aspects from the physical exam, found their expression as pen was firmly pressed to
Medscape Pediatrics © 2018 WebMD, LLC
Any views expressed above are the author's own and do not necessarily reflect the views of WebMD or Medscape.
Cite this: SOAP to EHR to Scribe: What's Next? - Medscape - Feb 23, 2018.
COMMENTARY
SOAP to EHR to Scribe: What's Next?
L. Gregory Lawton, MD
DisclosuresFebruary 23, 2018
Once upon a time, I wrote SOAP notes. Most clinicians remember what these were. These were notes written to document a patient encounter, be it in the office or in the hospital. It was divided into four sections:
Subjective: What did the patient say?
Objective: Vital signs, physical exam findings, labs results, imaging studies;
Assessment: What the clinician thinks is going on with the patient, alternative diagnoses; and
Plan: What is to be done to either clarify the clinical situation or help the patient.
I wrote my SOAP notes with a fountain pen. Most clinicians think this is weird. (Kids, on the other hand, tend to think that this is pretty neat, affording me the opportunity to introduce the concept of capillary action). My notes had the date and each letter of SOAP underlined with two short strokes. The penmanship was relatively neat, but the note was difficult to decipher owing to the shorthand.
The process of handwriting a progress note was an intimate experience. Personal details from the history, coupled with sensitive aspects from the physical exam, found their expression as pen was firmly pressed to
Medscape Pediatrics © 2018 WebMD, LLC
Any views expressed above are the author's own and do not necessarily reflect the views of WebMD or Medscape.
Cite this: SOAP to EHR to Scribe: What's Next? - Medscape - Feb 23, 2018.
Tables
Authors and Disclosures
Authors and Disclosures
Author
L. Gregory Lawton, MD
Pediatrician, CHOP Primary Care, HighPoint, Chalfont, Pennsylvania
Disclosure: L. Gregory Lawton, MD, has disclosed no relevant financial relationships.