SOAP to EHR to Scribe: What's Next? - Medscape

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 paper.

During my neonatal intensive care unit rotations, we thought we were so cool because we typed out our notes, copied labs and x-ray reports, and pasted them into the medical record. We were cutting-edge (or so we thought), as we touch-typed our notes and accelerated the process of "note bloat" (copying and pasting large chunks from the prior day's note into our current note, comfortable in the rationalization that there was little clinical change between day of life 32 and DOL 33 for this former 25-week preemie).

A Sea Change in Documentation

In September 2005, my clinical documentation world was forever altered as my institution, The Children's Hospital of Philadelphia (CHOP), moved to the electronic health record (EHR) in the ambulatory division. Gone were the days of paper charts, illegible notes (fountain pen-written or otherwise), coffee-stained problem lists, faded letters from outside specialists, et cetera.

This also meant less time looking into the eyes of the parent or patient.

Image from Alamy

Welcome to the world of clicks and typing and "mousing" around the screen.

When the EHR was introduced to our practice, several reasons were given. Notes would be more legible. They would be easier to track from day to day and would be accessible by other clinicians in other parts of the hospital. I seem to recall the phrase "aid in the coordination of care." Of course, this is all true, but there were also other reasons. Billing efficiency for one, research for another.

The research is of particular interest to the clinical informaticist in me. For a given patient (for whom there are such data points as age, sex, and ZIP code, among other) at a given encounter (eg, cardiology, radiology, primary care), on a given day, at a given time, there is a progress note (with embedded data points). Perhaps a medication is prescribed. Data fields exist on the name of the medication, formulation, directions, number of refills, and the pharmacy to which it is sent, to name a few. Let's not forget about labs and referrals.

In a phrase, practically every single, solitary time the enter key is hit, a discrete datum is created and stored, and becomes retrievable. Do you want (or need) to know the number of males between the ages of 65 and 75 who were prescribed ramipril 2.5 mg since July of last year? The data are there. The report to obtain the data can be requested.

Practically every single, solitary time the enter key is hit, a discrete datum is created and stored, and becomes retrievable.

This is the power of the EHR, but this leaves the front-line clinician, clicking away (while the patient is in the room or, alternatively, late at night, at home, after the kids and spouse have gone to bed) as a data entry chump. Sure, being able to quickly see the last cardiology note, plot the blood pressure trend line (complete with red arrows to indicate medication changes) is very cool, but it is not the SOAP note of old.

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