Institute:Office of National Coordinator (ONC) Workforce Training Curriculum
Component:The Culture of Health Care
Unit:Health Care Processes and Decision Making
Lecture:Making a diagnosis
Choosing therapy
The impact of EHRs and technology on clinical decision-making
Slide content:SOAP Process Model 4.10 Figure: By CAST, CC-BY 8
Slide notes:This slide illustrates the SOAP [soap] note format introduced by Lawrence Weed in his 1968 landmark article, Medical Records That Guide and Teach. This management tool was widely adopted in health care after its publication. According to this format, notes in the clinical record are recorded using the same structure for each patient problem. SOAP stands for subjective, objective, assessment, and plan. Subjective pertains to information obtained from the patient, and objective represents observations made by the clinician or obtained from the laboratory. Assessment refers to the clinicians determination of the problem and its severity, and plan is a management plan for this particular patient at this particular time. Note that the structure of Weeds SOAP note matches that of scientific argument, beginning with a statement of the problem, followed by presentation of the data, interpretation of the data, and conclusions about what should be done. Weed intended that clinicians would enforce this order to help them think clearly, considering the data before reaching a conclusion. The logic is embedded in the structure, and entering this information in a different order might result in different conclusions. Another aim of this system is to produce continuity over time. Weed suggested that each problem be given a specific number and that these numbers be used in each case that addresses this problem so that a particular condition can be followed over time. As predicted by Weed nearly 50 years ago, electronic medical records make this continuity much easier to achieve. Clinical information systems, electronic health records, and clinical decision support systems are just some of the electronic tools and technology used to support the patients management planespecially when the patient requires care from multiple providers in various settings. Electronically sharing the patients management plan with all participating providers facilitates effective transitions of care across the patient care continuum. Ideally, all providers on the care team should have access to and contribute to the patients record, which provides a holistic view of the patient. Health information exchange also supports the industrys ability to move toward value-based care insurance models as we move away from traditional insurance models. 8