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POMR and SOAP Notes

POMR and SOAP Notes

1 of 49
The Problem Orientated Medical Record
(POMR) and SOAP Note
Prepared and presented by
Marc Imhotep Cray, M.D.
Companion eNotes:
SOAP Notes w Application Exercises
Marc Imhotep Cray, M.D.
Documentation of H&P (critically important)
2
The comprehensive history and physical examination
(complete H&P or H&P) is vehicle used to document
 patient’s medical history
 physical examination findings
 diagnoses or medical problems
 diagnostic studies to be performed, and
 initial plan of care implemented to address problems identified
NB: Although obtaining a thorough history and performing a detailed
physical examination are critically important, the documentation of H&P is
equally important
 This record (medical record) is often used as the basis for entire course
of medical management for a patient
Marc Imhotep Cray, M.D.
Documentation of H&P (2)
3
 Failure
 to take an adequate history or
 to perform a detailed physical examination-or
 to recognize important findings
may lead to inadequate care of the patient
 Failure to document comprehensive H&P adequately could
have same result (i.e., inadequate care of the pt.)
Marc Imhotep Cray, M.D.
Purposes of the Patient’s Medical Record
4
 Purposes of patient’s medical record may be classified as follows:
Medical Purposes
1. To assist the physician in making diagnoses
2. To assist physicians, nurses, and others in care and treatment of patient
3. To serve as a record for teaching medicine and for clinical research
Legal Purposes
1. To document insurance claims for the patient
2. To serve as legal proof in cases of malpractice claims for injury or
compensation, cases of poisoning, and cases of homicide.
5
The Problem Orientated
Medical Record (POMR)
Marc Imhotep Cray, M.D.
Problem Orientated Medical Record (POMR)
Defined
6
 The POMR as initially defined by Lawrence Weed, MD, is the official
method of record keeping use by most medical centers across the world
and thus in most (if not all) undergraduate medical schools
 The SOAP note originates from the POMR
 SOAP is an acronym for Subjective, Objective, Assessment, and Plan
 POMR preserves data in an easily accessible way that encourages ongoing
assessment and revision of health care plan by all members of health care
team
 Proper use results in concise, complete and accurate record keeping
Marc Imhotep Cray, M.D.
Basic components of POMR & SOAP Note
7
 5 components of the POMR are:
1. Data Base-History, Physical Exam and Laboratory Data
2. Complete Problem List
3. Initial Plans
4. Daily Progress Note
5. Final Progress Note or Discharge Summary
 4 Components of the SOAP Note
1. Subjective=Medical History
2. Objective=Physical Examination & Laboratory / Diagnostic Investigations
3. Assessment=Problems/ Initial Impression(Hypotheses /DDx)
4. Plan= Diagnostic work up and Therapeutic management
 A plan is only as good as the diagnostic hypotheses that generated it
Again, SOAP note originates from POMR
Marc Imhotep Cray, M.D.
1. Data Base
8
 A data-base is collected before beginning process of
identifying patient's problems
 Data Base must include a complete history and physical exam
 Many hospitals include certain routine laboratory studies
(CBC, SMAC, EKG, chest x-ray, urinalysis, etc.) for each
patient admitted
o If these are available to admitting physician, they are to be
included in initial data base along with a history and physical
o As additional information is collected it is added to Data Base
Marc Imhotep Cray, M.D.
2. Complete Problem List
9
 After preforming the medical history and physical exam and
reviewing basic laboratory data and records (the data base)
the Problem List is constructed and recorded
 Construction of a Problem List is the initial step of what
physicians "really do“
 That is, once they have seen the patient, physicians think about and
define
o "what is wrong with the patient" or
o "what are this patient's problems"
Marc Imhotep Cray, M.D.
Complete Problem List (2)
10
 A problem is defined as anything that causes concern to patient
or to caregiver, including:
 physical abnormalities
 psychological disturbance, and
 socioeconomic problems
 List serves as an index to rest of record & is arranged in 4 or 5 columns:
1. a chronologic list of problems
2. date of each problem's onset
3. action taken
4. outcome (often its resolution), and
5. date of outcome
Marc Imhotep Cray, M.D.
Complete Problem List (3)
11
 Problems are either active or inactive  inactive problems
are usually prior, resolved medical or surgical illnesses that
are still important to be remembered
 Dr. Weed had defined an active problem as anything that
requires management or further diagnostic workup
 Physicians often get caught up in defining Problems and
Problem Lists, accusing each other of lumping, splitting, etc.
 This is unnecessary (see next slide for rational)
Marc Imhotep Cray, M.D.
Complete Problem List (4)
12
Important facts to be noted in constructing a problem list are these:
A. A problem should be defined at its highest level of defensibility
For example:
 A beginning medicine clerk (medical student-3) admits a patient with vomiting and confusion
 On physical exam patient is found to have muscle twitching and a pericardial friction rub
 The initial lab data reveals a BUN of 100 and potassium of 7.0 (both elevated)
 The student lists each of these abnormalities as a separate problem
• This listing of six problems tells us that beginning student does not recognize that all of these are
manifestations of one problem, uremia
 A second-year resident might have recorded Problem List as having only one problem, uremia, and
included all other abnormalities under that problem
 Both Problem Lists are acceptable
• Second-year resident is reflecting a higher degree of understanding
• Following day clerk's Problem List could be modified to facilitate more precise (and less lengthy)
daily progress notes
Marc Imhotep Cray, M.D.
Complete Problem List (5)
13
Prob.# Date Entered Problem List Problem Resolved
1 5/2/16 BUN 5/3 uremia
2 5/2/16 K 5/3 See #1
3 5/2/16 Muscle twitching 5/3 See #1
4 5/2/16 Pericardial friction rub 5/3  See #1
5 5/2/16 Vomiting 5/3  See #1
6 5/2/16 Confusion 5/3 See #1
 Resolving problem 2-6 under 1, uremia allows one daily progress note to be
written for that problem and tells an observer reading pt.'s chart that all signs
(Sn) and symptoms (Sx) in problems 2-6 are related to manifestations of uremia
 date 5/3 tells observer to see notes of that day to explain redefining of
Problem List
B. Problem List must include all abnormalities noted in initial data base
 Again, each abnormality need not be separately recorded, as explained above
Marc Imhotep Cray, M.D.
Complete Problem List (6)
14
C. The Problem List is refined as problems are either resolved
or further defined
1. Example Problem Resolved:
 A pt. is admitted with a fever and cough productive of yellow
sputum which on Gram stain reveals Gram positive intracellular
diplococci
 Pt. is treated for seven days with penicillin and on 5/9 problem
clinically and radiologically resolves
Prob.# Date Entered Problem List Problem Resolved
1 5/2 pneumococcal pneumonia 5/9 
 date 5/9 refers an observer to that date's progress note which will
explain why problem is considered resolved
Marc Imhotep Cray, M.D.
Complete Problem List (7)
15
2. Example Problem Further Defined:
 Consider first example of patient with uremia
 On day 5/7 a renal biopsy is done which reveals etiology of renal
failure Problem List would then show:
Prob.# Date Entered Problem List
Problem
Resolved
1 5/2
BUN 5/3 Uremia 5/7 Secondary to
membranous glomerulonephropathy
 Again the date of 5/7 will refer reader to progress note for that day
which should reveal result of renal biopsy
Marc Imhotep Cray, M.D.
Complete Problem List (8)
16
D. If initial data base is incomplete, Problem List must state so
Example: A FM patient who is admitted w upper GI bleeding has not had
a pelvic exam in 2 years
 A pelvic and Pap Smear are not done on admission b/c pt. is unstable
 Problem list must include a problem that states
Prob.# Date Entered Problem List Problem Resolved
2 5/2
Incomplete Data Base
Pelvic/Pap Not Done
 Once pt. is stable and pelvic exam/Pap smear is done, the problem is resolved
Prob.# Date Entered Problem List Problem Resolved
2 5/2
Incomplete Data Base 5/9
Pelvic/Pap Not Done
Pelvic/Pap Done-Nml
Marc Imhotep Cray, M.D.
Complete Problem List (9)
17
E. The Positive Review of Systems: Many physicians wonder what to do
with pt. who answers affirmatively for every question asked in review of
systems(ROS)
 Does each positive have to be recorded separately?  Obviously not!
Example: For an elderly, lonely FM who is admitted w a hip fracture and
whose PE nml except for hip and whose answers are positive for every
question asked in ROS physician could list the problems:
 #1 - Fracture left hip, and
 #2 - Positive review of systems
 Or, recognizing that all these affirmatives may be manifestations of
depression physician could list #2 - Depression
Marc Imhotep Cray, M.D.
Initial Plans
18
 Next process that a physician undertakes after deciding "what
is wrong" is "what to do about what is wrong"
 This is the initial plan and must be written by admitting
physician after Problem List is constructed
 For each problem defined, a SOAP note must be recorded
Marc Imhotep Cray, M.D.
Initial Plans (2)
19
 Each separate problem is named and described in write up and,
subsequently, on the progress note in a SOAP format:
 S, subjective data from the patient's point of view
 O, objective data acquired by inspection, percussion, auscultation, and
palpation and from laboratory and radiologic tests, ECG etc.
 A, assessment of problem  an analysis of subjective and objective
data, and
 P, plan, including further diagnostic work, therapy, and pt. education
and (or) counseling
Marc Imhotep Cray, M.D.
Initial Plans (3)
20
Again, for each problem defined, a SOAP note must be recorded
Subjective and Objective are each a brief review of abnormalities
identified in history, physical, and initial lab data, which pertain to that
particular problem
 These need not be lengthy, but simply one or two lines reviewing
pertinent data (positive findings and pertinent negatives)
Marc Imhotep Cray, M.D.
Initial Plans (4)
21
 Assessment is a brief but pertinent paragraph describing what
physician thinks about that particular problem
 If problem recorded is a sign or symptom requiring a differential
diagnosis the DDx must be recorded in a prioritized manner with a
brief statement as to why physician includes the differential that he or
she does
 If problem is a known diagnosis (Ex.-asthma) physician must include
in Assessment a statement that describes severity and why problem
has worsened requiring admission to hospital
Marc Imhotep Cray, M.D.
Initial Plans (5)
22
Plan must include three distinct groupings:
1. Diagnostic Plan:
 diagnostic plan includes all diagnostic workup which admitting physician
feels will be necessary
 If Assessment includes differential diagnosis, each must be ruled in or
ruled out in diagnostic plan may be done by way of a Venn diagram
 Example: Consider a 23 year old FM admitted with pleuritic chest pain for which
admitting physician includes pulmonary embolus, pericarditis, or viral pleuritis in
differential diagnosis The diagnostic plan may be as follows:
Marc Imhotep Cray, M.D.
Initial Plans (6)
23
 If problem is a known diagnosis, then diagnostic plan must include
additional workup needed either to further define problem or to
assess severity of problem
2. Therapeutic Plan: Must detail all initial therapies started and
their rational
3. Patient Education Plan: Details initiation of plans to educate
patient of what problem is and how pt. will deal with it in
future
Marc Imhotep Cray, M.D.
Daily Progress Notes
24
 Many physicians object to POMR b/c its use results in lengthy,
redundant progress notes
 However, when used properly, POMR does just the opposite
and results in notes that are clear, direct, brief and complete
 A few helpful hints regarding SOAP progress notes are:
a. A note for each active problem identified need not be written
every day
 If nothing has changed regarding a particular problem, a
note for that problem need not be written
o An observer will refer back to prior day=s note to get a
progress report on that particular problem
Marc Imhotep Cray, M.D.
Daily Progress Notes (2)
25
b. The S, O, A, or P need not be rewritten if nothing is changed for that
particular aspect of the problem
c. A common error in writing daily progress notes concerns restating
problem under Assessment in daily note
 Example: If problem is congestive heart failure, Assessment for that
particular problem on any day cannot be “CHF"  This is simply a
restatement of problem
o However, physician must give a status report (example - better,
worse, or etiology determined) under assessment
Marc Imhotep Cray, M.D.
Final Progress Note or Discharge Summary
26
 Final progress note should include all active problems, each defined as
to its furthest resolution on Problem List
 The Subjective should include a brief review of course of symptoms
 The Objective should review course of objective parameters
 The Assessment and Plan should include probable course to follow
and define end-points as a guide for further therapy
 Emphasis on final progress note should be unresolved problems
 Problems which are resolved can be written up briefly
27
The SOAP Note
“SOAP note originated from POMR”
Marc Imhotep Cray, M.D.
Components of a SOAP note
28
 The four components of a SOAP note are:
Subjective,
Objective,
Assessment, and
Plan
 Length and focus of each component of a SOAP note vary
depending on specialty for instance, a surgical SOAP note
is likely to be much briefer than a medical SOAP note, and
will focus on issues that relate to post-surgical status
Marc Imhotep Cray, M.D.
Subjective component
29
 Initially is patient's Chief Complaint, or CC
 This is a very brief statement of patient (quoted) as to purpose of
office visit or hospitalization
 If this is first time a physician is seeing a patient physician will take a
detailed History of Present Illness (HPI)
 This describes patient's current condition in a chronological
narrative form
 HPI or state of experienced symptoms should be recorded in
patient's own words
Marc Imhotep Cray, M.D.
Subjective component (2)
30
 All information pertaining to subjective information is
communicated to physician by patient or his/her representative
 It should include all positive and pertinent negative symptoms
 Pertinent past medical history and surgical history, family history,
and social history, along with current medications, smoking status,
drug/alcohol/caffeine use, level of physical activity and allergies, are
also recorded
 Subsequent visits for same problem briefly summarize HPI,
including pertinent testing + results, referrals, treatments,
outcomes and follow-ups
Marc Imhotep Cray, M.D.
Subjective component (3)
31
 The mnemonic below refers to information a physician should elicit
(using pain as CC) before referring to patient's "old charts" or "old carts"
Onset
Location
Duration
CHaracter (sharp, dull, etc.)
Alleviating/Aggravating factors
Radiation
Temporal pattern (every morning, all day, etc./Timing)
Severity
Marc Imhotep Cray, M.D.
Subjective component (4)
32
Variants on “old carts” include LOCQSMAT (and OPQRST, to follow.)
Location
Onset (when and mechanism of injury - if applicable)
Chronology (better or worse since onset, episodic, variable, constant,
etc.)
Quality (sharp, dull, etc.)
Severity (usually a pain rating)
Modifying factors (what aggravates/reduces symptoms - activities,
postures, drugs, etc.)
Additional symptoms (un/related or significant Sx to the chief CC)
Treatment (has pt. seen another provider for this symptom?)
Marc Imhotep Cray, M.D.
Subjective component (5)
33
 OPQRST is a mnemonic used by medical professionals to accurately
discern reasons for a patient's symptoms and history in event of an
acute illness
 NB: It is specifically adapted to elicit Sx of a possible MI
 Each letter stands for an line of questioning for pt. CC evaluation
 Onset of the event
 Provocation or palliation
 Quality of the pain
 Region and radiation
 Severity
 Time (history)
Marc Imhotep Cray, M.D.
Subjective component (6)
34
 OPQRST is usually taken along w Vital Signs and “SAMPLE history” (next
slide)  recorded by person delivering care such as in "Subjective" portion
of a SOAP note, for later reference
o "PQRST" (omitting "O") is sometimes used instead
o The term "OPQRST-AAA" adds
• “Aggravating/alleviating factors",
• “Associated symptoms", and
• “Attributions/adaptations"
Marc Imhotep Cray, M.D.
Subjective component (7)
35
 A SAMPLE history is one method of obtaining information from a patient
 SAMPLE history is an mnemonic acronym to remember key questions for a
person's medical assessment (most commonly used in emergency medicine)
S – Signs/Symptoms (Sx are important but they are subjective)
A – Allergies
M – Medications
P – Past Illnesses
L – Last Oral Intake (sometimes also Last Menstrual Cycle)
E – Events Leading Up To Present Illness / Injury history which places a
greater emphasis on a person's medical history
 Again, SAMPLE Hx is sometimes used in conjunction w VS and OPQRST
Marc Imhotep Cray, M.D.
Parts of mnemonic OPQRST
36
Onset of the event
 What patient was doing when it started (active, inactive,
stressed)
 Whether pt. believes activity prompted pain, and
 Whether onset was sudden, gradual or part of an ongoing
chronic problem
Provocation or palliation
 Whether any movement, pressure (such as palpation) or
other external factor makes problem better or worse
 This can also include whether symptoms relieve with rest
Marc Imhotep Cray, M.D.
Parts of mnemonic OPQRST (2)
37
Quality of the pain
 This is patient's description of pain
o Questions can be open ended ("Can you describe the
pain for me?") or leading (“Is the pain sharp or dull?”)
 Ideally, this will elicit descriptions of patient's pain:
o whether it is sharp, dull, crushing, burning, tearing, or
some other feeling, along with pattern, such as
intermittent, constant, or throbbing
Marc Imhotep Cray, M.D.
Parts of mnemonic OPQRST (3)
38
Region and radiation
 Where pain is on body and whether it radiates (extends) or
moves to any other area
o This can give indications for conditions such as a
myocardial infarction can radiate through jaw neck
and arms
• Other referred pains can provide clues to underlying medical
causes
Marc Imhotep Cray, M.D.
Parts of mnemonic OPQRST (4)
39
Severity = Pain score (usually on a scale of 0 to 10) Zero is no pain and
ten is worst possible pain
 Can be comparative (such as "... compared to worst pain you have ever
experienced") or imaginative ("... compared to having your arm ripped off ")
o If pain is compared to a prior event, nature of that event may be a
follow-up question
 Physician must decide whether a score given is realistic within their
experience  for example, a pain score 10 for a stubbed toe is likely to be
exaggerated
 This may also be assessed for pain now, compared to pain at time of
onset, or pain on movement
Marc Imhotep Cray, M.D.
Parts of mnemonic OPQRST (5)
40
Time (history)
 How long condition has been going on and how it has
changed since onset (better, worse, different symptoms)
 Whether it has ever happened before
 Whether and how it may have changed since onset, and
 When the pain stopped if it is no longer currently being felt
Marc Imhotep Cray, M.D.
Objective component
41
The objective section of SOAP includes information that physician
observes, elicits and measures from patient's current presentation
Objective component includes:
 Vital signs (Temp., BP, Pulse, RR) and measurements, such as Weight and Height
 Findings from physical examinations, including
 Basic systems of cardiac and respiratory, affected systems
 Possible involvement of other systems,
 Pertinent normal findings and abnormalities
 Results from laboratory and other diagnostic tests already completed
Marc Imhotep Cray, M.D.
Assessment
42
 A medical diagnosis (Dx) for purpose of medical visit on given date of
note written
 it is a cogent & concise summary of patient w main
Sx/Sn/Labs=Dx, including a differential diagnosis (DDx) a list of
other possible diagnoses in order of most likely to least likely
 Assessment will also include possible and likely etiologies of patient's
problem
 Assessment also records a patient's progress since last visit, and
overall progress towards patient's goal from physician's perspective
Marc Imhotep Cray, M.D.
Plan
43
 Plan is what physician will do to treat patient's concerns (problems) 
such as ordering further labs, radiological work up, ECG, referrals given,
procedures performed, medications given and education/ counseling
provided
 Plan should also include goals of therapy and patient-specific drug and
disease-state monitoring parameters
 This should address each item of differential diagnosis
 For patients who have multiple health problems that are addressed in
SOAP note a plan is developed for each problem and is numbered
accordingly based on severity and urgency for therapy
 A note of what was discussed or advised with pt. as well as timings
for further review or follow-up should also be included
Note: Often Assessment and Plan components are grouped together
Marc Imhotep Cray, M.D.
Example SOAP note
44
 Example for a patient being reviewed following an appendectomy
 resembles a surgical SOAP note medical notes tend to be more detailed,
especially in subjective and objective components
Surgery Service, Dr. J
S:
No further Chest Pain or Shortness of Breath. "Feeling better today." Patient
reports headache.
O: Afebrile, P 84, R 16, BP 130/82. No acute distress.
Neck no JVD, Lungs clear
Cor RRR
Abd Bowel sounds present, mild RLQ tenderness, less than yesterday. Wounds look clean.
Ext without edema
A:
Patient is a 37-year-old man on post-operative day 2 for laparoscopic appendectomy.
Recovering well.
P:
Advance diet. Continue to monitor labs. Follow-up with Cardiology within three days of
discharge for stress testing as an out-patient. Prepare for discharge home tomorrow morning.
Marc Imhotep Cray, M.D.
Example SOAP note (2)
45
 The plan (previous slide) itself includes various components:
 Diagnostic component - continue to monitor labs
 Therapeutic component - advance diet
 Referrals - Follow up with Cardiology within three days of discharge
for stress testing as an out-patient.
 Patient education component - that is progressing well
 Disposition component - discharge to home in the morning
Marc Imhotep Cray, M.D.
Electronic Medical Records (EMR)
46
 Over past 30 years, medical informatics experts have
continued to develop electronic medical record
 Technologic advances allow recording of all patient information,
including clinical documentation, laboratory tests and imaging
studies directly into electronic record
 Access to record is password protected and encrypted
information is readily transmitted electronically within an
institution and around the world
 Multiple providers can have simultaneous access to record from any
computer terminal, allowing improved patient care simultaneously by
multiple clinicians
Marc Imhotep Cray, M.D.
EMR (2)
47
An increasing problem encountered with EMR is the “cut and
paste” phenomena:
 documentation from one day is cut and pasted to next rather
than constructed anew, and a deluge of laboratory and radiologic
information is pasted into daily progress notes and discharge
summaries
o These are both abuses of electronic format that are to be condemned
o Neither requires that cutter-paster has actually read material, given it
any thought, or reflected upon whole of information to form a new and
evolving clinical assessment and management plan
 NB: Each daily note should be constructed in its entirety each day, with
appropriate references to existing records
48
THE END
See next slide for links to tools and resources for further study.
Marc Imhotep Cray, M.D.
Further Study:
49
e-Book:
Kettenbach G. Writing SOAP Notes, 2nd Ed. Philadelphia PA: F. A. Davis Company, 1995.
https://drive.google.com/file/d/0B-tlCbPSHvfZamVyMjl0SFBvVDA/view?usp=sharing
Web:
 Alert: Lawrence Weed, father of the Problem Oriented Medical Record, looks ahead e-Patient Dave .November 28, 2011.
Available at: http://e-patients.net/archives/2011/11/alert-lawrence-weed-father-of-the-problem-oriented-medical-record-looks-
ahead.html
 Jacobs L. Interview with Lawrence Weed, MD—The Father of the Problem-Oriented Medical Record Looks Ahead. EDITORIAL: The
Permanente Journal/ Summer 2009/ Volume 13 No. 3 Available at
http://www.thepermanentejournal.org/files/Summer2009/Lawrence_Weed.pdf
 Donnelly WJ. Viewpoint: Patient-Centered Medical Care Requires a Patient-Centered Medical Record Pdf.
 Kernisan L. The Problem-Oriented Medical Record Available at http://thehealthcareblog.com/blog/2013/05/10/the-problem-
oriented-medical-record/ Accessed October 28, 2015
 Kernisan L. Medicine in Denial: What Larry Weed Can Teach Us About Patient Empowerment. The Health Care Blog (This post is
Part 2 of a commentary on “Medicine in Denial,” (2011) by Dr. Lawrence Weed and Lincoln Weed.) Available at:
http://thehealthcareblog.com/blog/2013/05/22/medicine-in-denial-what-larry-weed-can-teach-us-about-patient-
empowerment/ Accessed October 28, 2014
 Salmon P, Rappaport A, Bainbridge M, Hayes G, Williams J. Taking the problem oriented medical record forward. Primary Health
Care Specialist Group of the British Computer Society. https://drive.google.com/file/d/0B-
tlCbPSHvfZMlZnMU9sRFBNUWM/view?usp=sharing
 The SOAP format enhances communication: the SOAP format provides a clear and concise way of documenting patient
information. https://drive.google.com/file/d/0B-tlCbPSHvfZYVdGSy15NzhwRjg/view?usp=sharing

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POMR and SOAP Notes

  • 1. The Problem Orientated Medical Record (POMR) and SOAP Note Prepared and presented by Marc Imhotep Cray, M.D. Companion eNotes: SOAP Notes w Application Exercises
  • 2. Marc Imhotep Cray, M.D. Documentation of H&P (critically important) 2 The comprehensive history and physical examination (complete H&P or H&P) is vehicle used to document  patient’s medical history  physical examination findings  diagnoses or medical problems  diagnostic studies to be performed, and  initial plan of care implemented to address problems identified NB: Although obtaining a thorough history and performing a detailed physical examination are critically important, the documentation of H&P is equally important  This record (medical record) is often used as the basis for entire course of medical management for a patient
  • 3. Marc Imhotep Cray, M.D. Documentation of H&P (2) 3  Failure  to take an adequate history or  to perform a detailed physical examination-or  to recognize important findings may lead to inadequate care of the patient  Failure to document comprehensive H&P adequately could have same result (i.e., inadequate care of the pt.)
  • 4. Marc Imhotep Cray, M.D. Purposes of the Patient’s Medical Record 4  Purposes of patient’s medical record may be classified as follows: Medical Purposes 1. To assist the physician in making diagnoses 2. To assist physicians, nurses, and others in care and treatment of patient 3. To serve as a record for teaching medicine and for clinical research Legal Purposes 1. To document insurance claims for the patient 2. To serve as legal proof in cases of malpractice claims for injury or compensation, cases of poisoning, and cases of homicide.
  • 6. Marc Imhotep Cray, M.D. Problem Orientated Medical Record (POMR) Defined 6  The POMR as initially defined by Lawrence Weed, MD, is the official method of record keeping use by most medical centers across the world and thus in most (if not all) undergraduate medical schools  The SOAP note originates from the POMR  SOAP is an acronym for Subjective, Objective, Assessment, and Plan  POMR preserves data in an easily accessible way that encourages ongoing assessment and revision of health care plan by all members of health care team  Proper use results in concise, complete and accurate record keeping
  • 7. Marc Imhotep Cray, M.D. Basic components of POMR & SOAP Note 7  5 components of the POMR are: 1. Data Base-History, Physical Exam and Laboratory Data 2. Complete Problem List 3. Initial Plans 4. Daily Progress Note 5. Final Progress Note or Discharge Summary  4 Components of the SOAP Note 1. Subjective=Medical History 2. Objective=Physical Examination & Laboratory / Diagnostic Investigations 3. Assessment=Problems/ Initial Impression(Hypotheses /DDx) 4. Plan= Diagnostic work up and Therapeutic management  A plan is only as good as the diagnostic hypotheses that generated it Again, SOAP note originates from POMR
  • 8. Marc Imhotep Cray, M.D. 1. Data Base 8  A data-base is collected before beginning process of identifying patient's problems  Data Base must include a complete history and physical exam  Many hospitals include certain routine laboratory studies (CBC, SMAC, EKG, chest x-ray, urinalysis, etc.) for each patient admitted o If these are available to admitting physician, they are to be included in initial data base along with a history and physical o As additional information is collected it is added to Data Base
  • 9. Marc Imhotep Cray, M.D. 2. Complete Problem List 9  After preforming the medical history and physical exam and reviewing basic laboratory data and records (the data base) the Problem List is constructed and recorded  Construction of a Problem List is the initial step of what physicians "really do“  That is, once they have seen the patient, physicians think about and define o "what is wrong with the patient" or o "what are this patient's problems"
  • 10. Marc Imhotep Cray, M.D. Complete Problem List (2) 10  A problem is defined as anything that causes concern to patient or to caregiver, including:  physical abnormalities  psychological disturbance, and  socioeconomic problems  List serves as an index to rest of record & is arranged in 4 or 5 columns: 1. a chronologic list of problems 2. date of each problem's onset 3. action taken 4. outcome (often its resolution), and 5. date of outcome
  • 11. Marc Imhotep Cray, M.D. Complete Problem List (3) 11  Problems are either active or inactive  inactive problems are usually prior, resolved medical or surgical illnesses that are still important to be remembered  Dr. Weed had defined an active problem as anything that requires management or further diagnostic workup  Physicians often get caught up in defining Problems and Problem Lists, accusing each other of lumping, splitting, etc.  This is unnecessary (see next slide for rational)
  • 12. Marc Imhotep Cray, M.D. Complete Problem List (4) 12 Important facts to be noted in constructing a problem list are these: A. A problem should be defined at its highest level of defensibility For example:  A beginning medicine clerk (medical student-3) admits a patient with vomiting and confusion  On physical exam patient is found to have muscle twitching and a pericardial friction rub  The initial lab data reveals a BUN of 100 and potassium of 7.0 (both elevated)  The student lists each of these abnormalities as a separate problem • This listing of six problems tells us that beginning student does not recognize that all of these are manifestations of one problem, uremia  A second-year resident might have recorded Problem List as having only one problem, uremia, and included all other abnormalities under that problem  Both Problem Lists are acceptable • Second-year resident is reflecting a higher degree of understanding • Following day clerk's Problem List could be modified to facilitate more precise (and less lengthy) daily progress notes
  • 13. Marc Imhotep Cray, M.D. Complete Problem List (5) 13 Prob.# Date Entered Problem List Problem Resolved 1 5/2/16 BUN 5/3 uremia 2 5/2/16 K 5/3 See #1 3 5/2/16 Muscle twitching 5/3 See #1 4 5/2/16 Pericardial friction rub 5/3  See #1 5 5/2/16 Vomiting 5/3  See #1 6 5/2/16 Confusion 5/3 See #1  Resolving problem 2-6 under 1, uremia allows one daily progress note to be written for that problem and tells an observer reading pt.'s chart that all signs (Sn) and symptoms (Sx) in problems 2-6 are related to manifestations of uremia  date 5/3 tells observer to see notes of that day to explain redefining of Problem List B. Problem List must include all abnormalities noted in initial data base  Again, each abnormality need not be separately recorded, as explained above
  • 14. Marc Imhotep Cray, M.D. Complete Problem List (6) 14 C. The Problem List is refined as problems are either resolved or further defined 1. Example Problem Resolved:  A pt. is admitted with a fever and cough productive of yellow sputum which on Gram stain reveals Gram positive intracellular diplococci  Pt. is treated for seven days with penicillin and on 5/9 problem clinically and radiologically resolves Prob.# Date Entered Problem List Problem Resolved 1 5/2 pneumococcal pneumonia 5/9   date 5/9 refers an observer to that date's progress note which will explain why problem is considered resolved
  • 15. Marc Imhotep Cray, M.D. Complete Problem List (7) 15 2. Example Problem Further Defined:  Consider first example of patient with uremia  On day 5/7 a renal biopsy is done which reveals etiology of renal failure Problem List would then show: Prob.# Date Entered Problem List Problem Resolved 1 5/2 BUN 5/3 Uremia 5/7 Secondary to membranous glomerulonephropathy  Again the date of 5/7 will refer reader to progress note for that day which should reveal result of renal biopsy
  • 16. Marc Imhotep Cray, M.D. Complete Problem List (8) 16 D. If initial data base is incomplete, Problem List must state so Example: A FM patient who is admitted w upper GI bleeding has not had a pelvic exam in 2 years  A pelvic and Pap Smear are not done on admission b/c pt. is unstable  Problem list must include a problem that states Prob.# Date Entered Problem List Problem Resolved 2 5/2 Incomplete Data Base Pelvic/Pap Not Done  Once pt. is stable and pelvic exam/Pap smear is done, the problem is resolved Prob.# Date Entered Problem List Problem Resolved 2 5/2 Incomplete Data Base 5/9 Pelvic/Pap Not Done Pelvic/Pap Done-Nml
  • 17. Marc Imhotep Cray, M.D. Complete Problem List (9) 17 E. The Positive Review of Systems: Many physicians wonder what to do with pt. who answers affirmatively for every question asked in review of systems(ROS)  Does each positive have to be recorded separately?  Obviously not! Example: For an elderly, lonely FM who is admitted w a hip fracture and whose PE nml except for hip and whose answers are positive for every question asked in ROS physician could list the problems:  #1 - Fracture left hip, and  #2 - Positive review of systems  Or, recognizing that all these affirmatives may be manifestations of depression physician could list #2 - Depression
  • 18. Marc Imhotep Cray, M.D. Initial Plans 18  Next process that a physician undertakes after deciding "what is wrong" is "what to do about what is wrong"  This is the initial plan and must be written by admitting physician after Problem List is constructed  For each problem defined, a SOAP note must be recorded
  • 19. Marc Imhotep Cray, M.D. Initial Plans (2) 19  Each separate problem is named and described in write up and, subsequently, on the progress note in a SOAP format:  S, subjective data from the patient's point of view  O, objective data acquired by inspection, percussion, auscultation, and palpation and from laboratory and radiologic tests, ECG etc.  A, assessment of problem  an analysis of subjective and objective data, and  P, plan, including further diagnostic work, therapy, and pt. education and (or) counseling
  • 20. Marc Imhotep Cray, M.D. Initial Plans (3) 20 Again, for each problem defined, a SOAP note must be recorded Subjective and Objective are each a brief review of abnormalities identified in history, physical, and initial lab data, which pertain to that particular problem  These need not be lengthy, but simply one or two lines reviewing pertinent data (positive findings and pertinent negatives)
  • 21. Marc Imhotep Cray, M.D. Initial Plans (4) 21  Assessment is a brief but pertinent paragraph describing what physician thinks about that particular problem  If problem recorded is a sign or symptom requiring a differential diagnosis the DDx must be recorded in a prioritized manner with a brief statement as to why physician includes the differential that he or she does  If problem is a known diagnosis (Ex.-asthma) physician must include in Assessment a statement that describes severity and why problem has worsened requiring admission to hospital
  • 22. Marc Imhotep Cray, M.D. Initial Plans (5) 22 Plan must include three distinct groupings: 1. Diagnostic Plan:  diagnostic plan includes all diagnostic workup which admitting physician feels will be necessary  If Assessment includes differential diagnosis, each must be ruled in or ruled out in diagnostic plan may be done by way of a Venn diagram  Example: Consider a 23 year old FM admitted with pleuritic chest pain for which admitting physician includes pulmonary embolus, pericarditis, or viral pleuritis in differential diagnosis The diagnostic plan may be as follows:
  • 23. Marc Imhotep Cray, M.D. Initial Plans (6) 23  If problem is a known diagnosis, then diagnostic plan must include additional workup needed either to further define problem or to assess severity of problem 2. Therapeutic Plan: Must detail all initial therapies started and their rational 3. Patient Education Plan: Details initiation of plans to educate patient of what problem is and how pt. will deal with it in future
  • 24. Marc Imhotep Cray, M.D. Daily Progress Notes 24  Many physicians object to POMR b/c its use results in lengthy, redundant progress notes  However, when used properly, POMR does just the opposite and results in notes that are clear, direct, brief and complete  A few helpful hints regarding SOAP progress notes are: a. A note for each active problem identified need not be written every day  If nothing has changed regarding a particular problem, a note for that problem need not be written o An observer will refer back to prior day=s note to get a progress report on that particular problem
  • 25. Marc Imhotep Cray, M.D. Daily Progress Notes (2) 25 b. The S, O, A, or P need not be rewritten if nothing is changed for that particular aspect of the problem c. A common error in writing daily progress notes concerns restating problem under Assessment in daily note  Example: If problem is congestive heart failure, Assessment for that particular problem on any day cannot be “CHF"  This is simply a restatement of problem o However, physician must give a status report (example - better, worse, or etiology determined) under assessment
  • 26. Marc Imhotep Cray, M.D. Final Progress Note or Discharge Summary 26  Final progress note should include all active problems, each defined as to its furthest resolution on Problem List  The Subjective should include a brief review of course of symptoms  The Objective should review course of objective parameters  The Assessment and Plan should include probable course to follow and define end-points as a guide for further therapy  Emphasis on final progress note should be unresolved problems  Problems which are resolved can be written up briefly
  • 27. 27 The SOAP Note “SOAP note originated from POMR”
  • 28. Marc Imhotep Cray, M.D. Components of a SOAP note 28  The four components of a SOAP note are: Subjective, Objective, Assessment, and Plan  Length and focus of each component of a SOAP note vary depending on specialty for instance, a surgical SOAP note is likely to be much briefer than a medical SOAP note, and will focus on issues that relate to post-surgical status
  • 29. Marc Imhotep Cray, M.D. Subjective component 29  Initially is patient's Chief Complaint, or CC  This is a very brief statement of patient (quoted) as to purpose of office visit or hospitalization  If this is first time a physician is seeing a patient physician will take a detailed History of Present Illness (HPI)  This describes patient's current condition in a chronological narrative form  HPI or state of experienced symptoms should be recorded in patient's own words
  • 30. Marc Imhotep Cray, M.D. Subjective component (2) 30  All information pertaining to subjective information is communicated to physician by patient or his/her representative  It should include all positive and pertinent negative symptoms  Pertinent past medical history and surgical history, family history, and social history, along with current medications, smoking status, drug/alcohol/caffeine use, level of physical activity and allergies, are also recorded  Subsequent visits for same problem briefly summarize HPI, including pertinent testing + results, referrals, treatments, outcomes and follow-ups
  • 31. Marc Imhotep Cray, M.D. Subjective component (3) 31  The mnemonic below refers to information a physician should elicit (using pain as CC) before referring to patient's "old charts" or "old carts" Onset Location Duration CHaracter (sharp, dull, etc.) Alleviating/Aggravating factors Radiation Temporal pattern (every morning, all day, etc./Timing) Severity
  • 32. Marc Imhotep Cray, M.D. Subjective component (4) 32 Variants on “old carts” include LOCQSMAT (and OPQRST, to follow.) Location Onset (when and mechanism of injury - if applicable) Chronology (better or worse since onset, episodic, variable, constant, etc.) Quality (sharp, dull, etc.) Severity (usually a pain rating) Modifying factors (what aggravates/reduces symptoms - activities, postures, drugs, etc.) Additional symptoms (un/related or significant Sx to the chief CC) Treatment (has pt. seen another provider for this symptom?)
  • 33. Marc Imhotep Cray, M.D. Subjective component (5) 33  OPQRST is a mnemonic used by medical professionals to accurately discern reasons for a patient's symptoms and history in event of an acute illness  NB: It is specifically adapted to elicit Sx of a possible MI  Each letter stands for an line of questioning for pt. CC evaluation  Onset of the event  Provocation or palliation  Quality of the pain  Region and radiation  Severity  Time (history)
  • 34. Marc Imhotep Cray, M.D. Subjective component (6) 34  OPQRST is usually taken along w Vital Signs and “SAMPLE history” (next slide)  recorded by person delivering care such as in "Subjective" portion of a SOAP note, for later reference o "PQRST" (omitting "O") is sometimes used instead o The term "OPQRST-AAA" adds • “Aggravating/alleviating factors", • “Associated symptoms", and • “Attributions/adaptations"
  • 35. Marc Imhotep Cray, M.D. Subjective component (7) 35  A SAMPLE history is one method of obtaining information from a patient  SAMPLE history is an mnemonic acronym to remember key questions for a person's medical assessment (most commonly used in emergency medicine) S – Signs/Symptoms (Sx are important but they are subjective) A – Allergies M – Medications P – Past Illnesses L – Last Oral Intake (sometimes also Last Menstrual Cycle) E – Events Leading Up To Present Illness / Injury history which places a greater emphasis on a person's medical history  Again, SAMPLE Hx is sometimes used in conjunction w VS and OPQRST
  • 36. Marc Imhotep Cray, M.D. Parts of mnemonic OPQRST 36 Onset of the event  What patient was doing when it started (active, inactive, stressed)  Whether pt. believes activity prompted pain, and  Whether onset was sudden, gradual or part of an ongoing chronic problem Provocation or palliation  Whether any movement, pressure (such as palpation) or other external factor makes problem better or worse  This can also include whether symptoms relieve with rest
  • 37. Marc Imhotep Cray, M.D. Parts of mnemonic OPQRST (2) 37 Quality of the pain  This is patient's description of pain o Questions can be open ended ("Can you describe the pain for me?") or leading (“Is the pain sharp or dull?”)  Ideally, this will elicit descriptions of patient's pain: o whether it is sharp, dull, crushing, burning, tearing, or some other feeling, along with pattern, such as intermittent, constant, or throbbing
  • 38. Marc Imhotep Cray, M.D. Parts of mnemonic OPQRST (3) 38 Region and radiation  Where pain is on body and whether it radiates (extends) or moves to any other area o This can give indications for conditions such as a myocardial infarction can radiate through jaw neck and arms • Other referred pains can provide clues to underlying medical causes
  • 39. Marc Imhotep Cray, M.D. Parts of mnemonic OPQRST (4) 39 Severity = Pain score (usually on a scale of 0 to 10) Zero is no pain and ten is worst possible pain  Can be comparative (such as "... compared to worst pain you have ever experienced") or imaginative ("... compared to having your arm ripped off ") o If pain is compared to a prior event, nature of that event may be a follow-up question  Physician must decide whether a score given is realistic within their experience  for example, a pain score 10 for a stubbed toe is likely to be exaggerated  This may also be assessed for pain now, compared to pain at time of onset, or pain on movement
  • 40. Marc Imhotep Cray, M.D. Parts of mnemonic OPQRST (5) 40 Time (history)  How long condition has been going on and how it has changed since onset (better, worse, different symptoms)  Whether it has ever happened before  Whether and how it may have changed since onset, and  When the pain stopped if it is no longer currently being felt
  • 41. Marc Imhotep Cray, M.D. Objective component 41 The objective section of SOAP includes information that physician observes, elicits and measures from patient's current presentation Objective component includes:  Vital signs (Temp., BP, Pulse, RR) and measurements, such as Weight and Height  Findings from physical examinations, including  Basic systems of cardiac and respiratory, affected systems  Possible involvement of other systems,  Pertinent normal findings and abnormalities  Results from laboratory and other diagnostic tests already completed
  • 42. Marc Imhotep Cray, M.D. Assessment 42  A medical diagnosis (Dx) for purpose of medical visit on given date of note written  it is a cogent & concise summary of patient w main Sx/Sn/Labs=Dx, including a differential diagnosis (DDx) a list of other possible diagnoses in order of most likely to least likely  Assessment will also include possible and likely etiologies of patient's problem  Assessment also records a patient's progress since last visit, and overall progress towards patient's goal from physician's perspective
  • 43. Marc Imhotep Cray, M.D. Plan 43  Plan is what physician will do to treat patient's concerns (problems)  such as ordering further labs, radiological work up, ECG, referrals given, procedures performed, medications given and education/ counseling provided  Plan should also include goals of therapy and patient-specific drug and disease-state monitoring parameters  This should address each item of differential diagnosis  For patients who have multiple health problems that are addressed in SOAP note a plan is developed for each problem and is numbered accordingly based on severity and urgency for therapy  A note of what was discussed or advised with pt. as well as timings for further review or follow-up should also be included Note: Often Assessment and Plan components are grouped together
  • 44. Marc Imhotep Cray, M.D. Example SOAP note 44  Example for a patient being reviewed following an appendectomy  resembles a surgical SOAP note medical notes tend to be more detailed, especially in subjective and objective components Surgery Service, Dr. J S: No further Chest Pain or Shortness of Breath. "Feeling better today." Patient reports headache. O: Afebrile, P 84, R 16, BP 130/82. No acute distress. Neck no JVD, Lungs clear Cor RRR Abd Bowel sounds present, mild RLQ tenderness, less than yesterday. Wounds look clean. Ext without edema A: Patient is a 37-year-old man on post-operative day 2 for laparoscopic appendectomy. Recovering well. P: Advance diet. Continue to monitor labs. Follow-up with Cardiology within three days of discharge for stress testing as an out-patient. Prepare for discharge home tomorrow morning.
  • 45. Marc Imhotep Cray, M.D. Example SOAP note (2) 45  The plan (previous slide) itself includes various components:  Diagnostic component - continue to monitor labs  Therapeutic component - advance diet  Referrals - Follow up with Cardiology within three days of discharge for stress testing as an out-patient.  Patient education component - that is progressing well  Disposition component - discharge to home in the morning
  • 46. Marc Imhotep Cray, M.D. Electronic Medical Records (EMR) 46  Over past 30 years, medical informatics experts have continued to develop electronic medical record  Technologic advances allow recording of all patient information, including clinical documentation, laboratory tests and imaging studies directly into electronic record  Access to record is password protected and encrypted information is readily transmitted electronically within an institution and around the world  Multiple providers can have simultaneous access to record from any computer terminal, allowing improved patient care simultaneously by multiple clinicians
  • 47. Marc Imhotep Cray, M.D. EMR (2) 47 An increasing problem encountered with EMR is the “cut and paste” phenomena:  documentation from one day is cut and pasted to next rather than constructed anew, and a deluge of laboratory and radiologic information is pasted into daily progress notes and discharge summaries o These are both abuses of electronic format that are to be condemned o Neither requires that cutter-paster has actually read material, given it any thought, or reflected upon whole of information to form a new and evolving clinical assessment and management plan  NB: Each daily note should be constructed in its entirety each day, with appropriate references to existing records
  • 48. 48 THE END See next slide for links to tools and resources for further study.
  • 49. Marc Imhotep Cray, M.D. Further Study: 49 e-Book: Kettenbach G. Writing SOAP Notes, 2nd Ed. Philadelphia PA: F. A. Davis Company, 1995. https://drive.google.com/file/d/0B-tlCbPSHvfZamVyMjl0SFBvVDA/view?usp=sharing Web:  Alert: Lawrence Weed, father of the Problem Oriented Medical Record, looks ahead e-Patient Dave .November 28, 2011. Available at: http://e-patients.net/archives/2011/11/alert-lawrence-weed-father-of-the-problem-oriented-medical-record-looks- ahead.html  Jacobs L. Interview with Lawrence Weed, MD—The Father of the Problem-Oriented Medical Record Looks Ahead. EDITORIAL: The Permanente Journal/ Summer 2009/ Volume 13 No. 3 Available at http://www.thepermanentejournal.org/files/Summer2009/Lawrence_Weed.pdf  Donnelly WJ. Viewpoint: Patient-Centered Medical Care Requires a Patient-Centered Medical Record Pdf.  Kernisan L. The Problem-Oriented Medical Record Available at http://thehealthcareblog.com/blog/2013/05/10/the-problem- oriented-medical-record/ Accessed October 28, 2015  Kernisan L. Medicine in Denial: What Larry Weed Can Teach Us About Patient Empowerment. The Health Care Blog (This post is Part 2 of a commentary on “Medicine in Denial,” (2011) by Dr. Lawrence Weed and Lincoln Weed.) Available at: http://thehealthcareblog.com/blog/2013/05/22/medicine-in-denial-what-larry-weed-can-teach-us-about-patient- empowerment/ Accessed October 28, 2014  Salmon P, Rappaport A, Bainbridge M, Hayes G, Williams J. Taking the problem oriented medical record forward. Primary Health Care Specialist Group of the British Computer Society. https://drive.google.com/file/d/0B- tlCbPSHvfZMlZnMU9sRFBNUWM/view?usp=sharing  The SOAP format enhances communication: the SOAP format provides a clear and concise way of documenting patient information. https://drive.google.com/file/d/0B-tlCbPSHvfZYVdGSy15NzhwRjg/view?usp=sharing