Subjective, Objective, Assessment, Plan Research Articles

Using Electronic Medical Records to Teach Patient-Centered Care

To develop, implement, and evaluate the use of electronic medical records (EMRs) in disease state management activities to teach pharmacy students patient-centered care skills. Faculty created 12 patient cases and an EMR for each simulated patient. Students used the information in the EMR to confirm the presence of a disease in their patient; to design and monitor an evidence-based patient-centered care plan, and document their assessment, medication, and monitoring recommendations; and to follow up in a SOAP (subjective, objective, assessment, plan) note format within the EMR. A precourse and postcourse survey instrument was administered to assess students' perceived gains in knowledge and attitudes regarding the use of EMRs for learning patient-centered care skills. A grading rubric was used to evaluate each SOAP note. Implementation of disease state management activities involving EMRs improved pharmacy students' patient care skills.

A repurposed tool: the Programme Evaluation SOAP Note

Doctors have used the subjective-objective-assessment-plan (SOAP) note format to organise data about patient problems and create plans to address each of them. We retooled this into the 'Programme Evaluation SOAP Note', which serves to broaden the clinician faculty member's perspective on programme evaluation to include the curriculum and the system, as well as students. The SOAP Note was chosen as the method for data recording because of its familiarity to clinician-educators and its strengths as a representation of a clinical problem-solving process with elements analogous to educational programme evaluation. We pilot-tested the Programme Evaluation SOAP Note to organise faculty members' interpretations of integrated student performances during the Year 3 patient care skills objective structured clinical examination (OSCE). Eight community clerkship directors and lead clerkship faculty members participated as observers in the 2007 gateway examination and completed the Programme Evaluation SOAP Note. Problems with the curriculum and system far outnumbered problems identified with students. Using the Programme Evaluation SOAP Note, clerkship leaders developed expanded lists of 'differential diagnoses' that could explain possible learner performance inadequacies in terms of system, curriculum and learner problems. This has informed programme improvement efforts currently underway. We plan to continue using the Programme Evaluation SOAP Note for ongoing programme improvement.

Patient Note Fabrication and Consequences of Unprofessional Behavior in a High-Stakes Clinical Skills Licensing Examination

The National Board of Osteopathic Medical Examiners (NBOME) administers the Comprehensive Osteopathic Medical Licensing Examination USA Level 2-PE (COMLEX-USA Level 2-PE) and has developed a process that links the competencies of written communication and professionalism by tracking fabrication in the postencounter SOAP (Subjective, Objective, Assessment, Plan) note exercise. A process used to identify potential SOAP note fabrication was implemented in the 2007-2008 test cycle for the COMLEX-USA Level 2-PE. A total of 3,753 candidates took the COMLEX-USA Level 2-PE in the 2007-2008 test cycle. Forty-eight candidates were screened, and the NBOME's Subcommittee on SOAP Note Fabrication made failure decisions on eight, leading to a failure rate of 0.2% based on fabrication review. The NBOME has adopted the stance that postencounter note fabrication represents unprofessional behavior. Screening for and failing candidates who exhibit unprofessional behavior enhances the validity of the examination.

Managing childhood fever in a prehospital setting

In 2007, the National Institute for Health and Clinical Excellence (NICE) produced guidelines on feverish illness in children concentrating specifically on assessment and initial management in children under 5 years. Fever has been identified as one of the most common reasons for children to be taken to their GP or the emergency department and a principal rationale for admission to children's wards. Usually fever indicates some underlying viral or bacterial infection, which is predominantly self-limiting. However, a few are serious in nature requiring urgent treatment, such as meningitis, septicaemia, urinary tract infection and pneumonia. It is imperative that prehospital health practitioners (paramedic technicians, emergency care practitioners, nurse practitioners) have an ability to think critically about the potential aetiologies displaying this clinical feature, an understanding of current evidence-based management guidelines and a commitment to standardize practice. The aim of this article is to explore and incorporate the NICE guidelines into an appraisal of the ill child presenting with a fever, using the SOAP (subjective, objective, assessment, plan) model of assessment (Weed, 1969) for structure. Furthermore, the physiology of fever will be outlined briefly to provide baseline underpinning knowledge and understanding.

Clinical documentation for patient care: Models, concepts, and liability considerations for pharmacists

A guide to the appropriate documentation of the critical aspects of the patient medical record to ensure reimbursement and the reduction of medical liability is presented. Several documentation styles can be adopted to record pharmacist interventions, including unstructured notes, semistructured notes, and systematic notes. Documentation should be clear, concise, legible, nonjudgmental, patient focused, and standardized, and it should ensure patient confidentiality. Systematic documentation styles include SOAP (subjective, objective, assessment, plan), TITRS (title, introduction, text, recommendation, signature), and FARM (findings, assessment, recommendations or resolutions, management). SOAP is the primary form for which payers traditionally reimburse. Systematic documentation should be used to demonstrate how pharmacist interventions improved patient care and should not just be used for reimbursement. Pharmacists have the opportunity to build a collaborative relationship with other professionals and with patients. Documentation can provide evidence of this symbiotic relationship where the pharmacist assists in providing a caring and compassionate environment for the patient's benefit. Professional liability, as it relates to clinical documentation, can be an issue. Documentation provides the necessary information to successfully manage the process of discovery and the review of the conduct of all parties involved in a liability issue. Documentation in a universal format allows for communication among health care practitioners. Written documentation is one key to a successful, open-communication partnership among providers. In addition, accurate, appropriate, and concise documentation is an essential component of ensuring that the patient care provided is evident, not only for patient safety and continuity but also for cases where reimbursement and quality of care are being challenged contractually or legally.

Web-Based Learning Versus Standardized Patients For Teaching Clinical Diagnosis: A Randomized, Controlled, Crossover Trial

Background: Little evidence exists to guide the selection of methods for teaching clinical diagnosis.Purpose: To compare the efficacy, student preference, and cost of a Web-based (WB) program versus a standardized patient (SP) encounter for teaching clinical diagnosis skills to 2nd-year medical students.Methods: Randomized, controlled, crossover study comparing WB versus SP-based teaching for the clinical diagnosis of abdominal pain and headache. Outcome measures were performance on a 2-case SP examination (scored on the basis of a checklist completed by a faculty observer and an objective score on a postencounter subjective-objective assessment plan [SOAP] note), format preferences as assessed by end-of-course evaluations, and cost.Results: Thirty students consented to participate. WB and SP training produced similar scores on both the Abdominal Pain checklist (66% vs. 62%; p =. 17) and Headache checklist (56% vs. 63%; p =. 07). WB training produced a higher score on the Abdominal Pain SOAP note (69% vs. 47%; p =. 006), but not the Headache SOAP note (69% vs. 67%; p =. 85). Students rated the SP format higher than the WB format on all 7 preference measures. Start-up costs were estimated at $2,190 for the SP format and $2,250 for the WB format. Ongoing costs per case per student were estimated to be $45 for the SP format and $30 for the WB format.Conclusions: WB and SP learning outcomes were comparable, but students preferred the SP format. Start-up costs were comparable, but the ongoing costs of the WB format were less expensive, suggesting that WB teaching may be a viable strategy.

Just a spoonful of humanities makes the medicine go down: introducing literature into a family medicine clerkship

This project introduced medicine-related poetry and prose to a Year 3 family medicine clerkship with the purpose of determining students' perception of the usefulness of such materials to enhance empathy, improve patient management, and reduce stress. Although humanities are represented in the curricula of many medical schools, we need more information on how best to incorporate them during the clinical years. In 2000, we used a needs assessment survey to identify learner perceptions of medical humanities. Using this information, in 2001-03 we developed and implemented a humanities-based curriculum consisting of readings linked to clinical vignettes, comments about humanities reading in required clinical Subjective, Objective, Assessment, Plan (SOAP) notes, and either station-specific or general poetry accompanying student end-of-clerkship objective structured clinical examinations. We collected both quantitative and qualitative data assessing student reactions and examined the data using non-parametric statistics and content analysis, respectively. Students showed moderate interest in incorporating humanities in medical education as a way of enhancing empathy, improving understanding and reducing frustration. Assessment of the clerkship humanities curriculum suggested a positive influence on students in terms of empathy for the patient's perspective, and a lesser, but still positive, impact on patient management. Responses from this group of learners suggest that there is receptivity toward introducing medical humanities into family medicine curricular venues and that such effort can have a generally positive effect on learner empathy, awareness and understanding toward patients and doctors.

Outpatient Osteopathic SOAP Note Form: preliminary results in osteopathic outcomes-based research.

One of the persistent challenges facing the osteopathic medical profession has been the lack of a reliable, easy-to-use, validated system for recording, collecting, and evaluating clinical findings in a format that is suitable for long-term data collection. As a result of the recent emphasis on outcomes-based research in the field of medicine, the creation and use of a standardized tool for the osteopathic profession has been pursued with increased urgency. In this study, the authors used participant-completed and previously validated Outpatient Osteopathic SOAP (Subjective, Objective, Assessment, Plan) Note Forms (SNFs) and Outpatient Osteopathic SOAP (Subjective, Objective, Assessment, Plan) Note--Follow-up Forms to obtain answers to 17 outcomes-based questions that the profession must address to meet the new challenges and demands of outcomes-based research. A consortium of 10 osteopathic physicians and 196 osteopathic residents and undergraduate fellows submitted a total of 3908 patient SNFs for analysis. Answers to these 17 questions were computed using appropriate statistical determinants (eg, frequencies, correlations). Retrospective analysis indicated that, in addition to the outcomes addressed in this study, use of the SNF could be extended to the following functions: pre- and postdoctoral tracking, outcomes research into the efficacy of osteopathic intervention, medical science research, autonomic correlation with disease entities, etiology of musculoskeletal dysfunction, billing information, and internal comparison studies between osteopathic physicians. A long-term goal of the SNF project is to create an electronic national database for osteopathic outcomes-based research.

Infertility classification: A work in progress sounds like SOAP revisited

Documentation and communication regarding infertility evaluation and management continue to be a work in progress. Grading systems focused on the degree of infertility and the associated prognosis are a step in the right direction. A subjective, objective, assessment, plan (SOAP) approach is a logical way to provide a detailed method of communication and documentation when dealing with infertile couples.

Viewpoint:

If patient-centered medicine is to become a widespread reality in academic medical centers, educational initiatives must include reform of the medical record. The medical record is part of the hidden, or informal, curriculum of medical school and residency that defines for students and residents the essential ingredients of competent medical care. Whatever its merits, the conventional, problem-oriented medical record (POMR) is a pathology-oriented record that helps perpetuate a disease-focused, biomedical model of practice Patient-centered medicine requires a patient-centered medical record (PCMR), one that addresses the person and perspective of the patient as competently as it addresses the patient's disease. The author proposes a PCMR that includes a concise, upfront Patient Profile; speaks of "chief concerns," not "chief complaints"; makes Patient Perspective a captioned component of the History of Present Illness; replaces the POMR's formula SOAP (Subjective, Objective, Assessment, Plan) with HOAP (History, Observations, Assessment, Plan); includes important patient perspectives on the Problem List; and calls for additional, written attention to the person and perspective of the patient throughout the course of medical care Patient-centered records can guide and teach clinicians at every level of training and experience to practice patient-centered medicine. Moreover, such records can also provide measurable evidence that this teaching has been successful.

Pharmaceutical Care Research and Education Project: Pharmacists' Interventions

To describe the processes of care used by community pharmacists participating in the Pharmaceutical Care Research and Education Project (PREP) in terms of drug-related problems (DRPs), pharmacists' recommendations, and status of DRPs at follow-up, and to determine characteristics associated with DRPs. Descriptive analysis of the treatment group from a larger randomized, controlled cluster design. Five independent community pharmacies in Alberta. One hundred fifty-nine patients who were covered under Alberta Health and Wellness's senior drug benefit plan (i.e., 65 years or older), were taking three or more medications concurrently according to pharmacy records, were able to complete telephone interviews as determined by pharmacists, maintained residence in Alberta for 12 of the 15 study months, agreed to receive their prescription medications only from the study pharmacy during the study period, and provided informed consent. Frequency of DRPs, recommendations, status of DRPs, and analysis of clinical results as determined during pharmacists' follow-up care. In telephone surveys, patients reported taking 4.7 prescription medications per day, but pharmacists documented 8.7 prescription medications per day in their records. Pharmacists documented 559 DRPs, a mean (+/- SD) of 3.9+/-3.2 problems per patient. Approximately 39% of problems were actual DRPs, while 60% were potential DRPs. Medical conditions associated most frequently with a DRP involved the respiratory, cardiovascular, and musculoskeletal systems. The most common DRP categories were "patient requires drug therapy" or "patient requires influenza or pneumococcal vaccination." Pharmacists wrote 551 initial clinical notes using the subjective, objective, assessment, plan (SOAP) format, and they recorded 346 follow-up interventions, also using SOAP notes. Counseling, preventive consultations, and clinical monitoring represented 40% of their recommendations. In 80% of situations, the pharmacist made the recommendation directly to the patient. On follow-up, 40% of the 559 DRPs identified were resolved, controlled, or improved. Patients accepted 76% of pharmacists' recommendations, and physicians accepted 72% of pharmacists' suggested resolutions of DRPs. Pharmacists were more likely to follow up about actual DRPs, as compared with potential ones; overall, they followed up on 62% of identified DRPs. Pharmacists identified more DRPs for study patients than previous community-based, observational studies have reported. Undertreatment appears to be a prevalent DRP. Community pharmacists' recommendations to prevent and resolve DRPs were made primarily to patients and were well accepted. More follow-up was needed for all DRPs. When follow-up occurred, the DRP results generally showed improvement.

New approach to the medical information system for quality management in patient care: development of Problem Mapping System.

A new type of medical information system named Problem Mapping System (P-Map) has been developed, which aids physicians with solving patients' problems. With this system, physicians can define the problems of in-patients, monitor their progress clearly, and share information efficiently. In P-map, a list of problems, such as disease names, can be set for each inpatient easily. The progress of each problem is clearly shown using progress lines on a time axis. Physicians can save the Subjective Objective Assessment Plan (SOAP) notes which are linked to each problem. At the final stage of patient care, a discharge summary can be made easily. With the aid of this system, the quality of patient care is improved due to the following: (1) physicians can make the best decision; (2) medical staff in the same team can provide the best medical treatment; (3) evaluation of each medical treatment is easy; (4) saved data can be used effectively for education and research; (5) the system can improve cooperation with other medical institutes by providing discharge summary information which can be distributed using e-mail; and (6) the system can improve patients' understanding for the purpose of informed consent by providing clear and well organized information to patients.

A Comparative Analysis of Two Methodologies for Documentation in the Patient Medical Record by the R.D

LEARNING OUTCOME: To evaluate two formats for documentation of initial nutrition assessment in the acute-care patient medical record. Documentation of initial nutrition assessment at one institution was completed in subjective, objective, assessment, plan (SOAP) format until 1994, when an Assessment Form was initiated to streamline the standardized documentation of R.D.s. The two formats were evaluated to determine the effectiveness of dietitians documentation practice. A retrospective chart review was completed using a random sample of charts from two groups of patients (SOAP/94, n=30; FORM/95-96, n=30) with a primary discharge diagnosis of cerebrovascular accident. Initial assessment documentation was completed sooner in the FORM/95-96 group (2.61 days) than the SOAP/94 group (4.31 days). Significantly more recommendations (p=<.001) for nutrition intervention were made in the FORM/95-96 (n=25) than the SOAP/94 group (n=9). For both groups significantly more recommendations were made by the R.D. when documentation was completed earlier in the patient hospital admission. The FORM/95-96 group showed an increasing trend in the total number of recommendations made by the R.D. and implemented by the Healthcare provider. Assessment form documentation, used with the FORM/95-96 group, for initial nutrition assessment was completed more frequently, in a more timely manner, and provided appropriate nutrition recommendations for patient centered care in the acute hospital setting.

A system-structured medical record for intensive care patient documentation.

The problem-oriented approach to the medical record has aroused a long overdue interest in the structuring of the medical case file. Clinical information in the traditional record is source-structured and time-sequenced, whereas the problem-oriented system differs by being a problem-structured record retaining still a chronologic sequence. We have found that in acute illness the multiplicity of interacting pathophysiologic processes makes premature application of the problem-oriented approach cumbersome and unwieldy. The formulation of the problem list at an early stage often led to the reduplication of problems, creating disorder in the clinical picture rather than serving to clarify it. Some used the simple cataloguing of events and data as a substitute for clinical judgment and decision making, focusing more upon style rather than content of the medical record. By using a rigid physiologic system-structured "problem" list and a modification of the SOAP (Subjective Objective, Assessment, Plan) subdivision, we have improved the documentation of our intensive care patients. The summary of the patient's stay in the intensive care unit is structured with active and inactive problems, this summary to be further used as the permanent problem list.