In 1968, Lawrence Weed, MD, developed the problem-oriented medical record (POMR) “… to develop a more organized approach to the medical record…” (Weed L. Medical records that guide and teach. NEJM Vol. 278, No. 11 & 12. 1968.) SOAP notes (Subjective, Objective, Assessment, Plan) – although only one component of the entire POMR – have become the standard in clinical record keeping for daily chart notes in ambulatory settings. Proper record keeping using the SOAP method improves patient care and enhances communication between the provider and other parties: claims personnel, peer reviewers, case managers, attorneys, and other physicians or providers who may assume the care of your patients.
The purpose of this post is to review accepted methods of clinical documentation using the SOAP format. CHP does not require, but strongly encourages the use of the SOAP format. If SOAP itself is not used, the elements embodied in SOAP must be recorded.
Basic best practices for SOAP format and other chart notes include:
- Legibility: Chart notes must be legible, preferably typed. If handwritten, they must be easy-to-read.
- The provider’s identification (name, address and phone) and patient’s name and unique identifier such as date of birth (DOB) or record number must be indicated on each side of each page of notes.
- Every chart entry must be dated. Each entry must be signed by the person entering the note (this includes office personnel who make entries in the chart).
- Standard abbreviations are acceptable as long as they are easily understandable and interpretable by the reader.
There are many styles of chart notes that can be effective. Narrative notes in SOAP format are the clinical standard. Effective chart notes must reflect the four criteria required to document medical necessity.
- The patient’s chart must reflect subjective findings that are consistent with a lesion, injury, or condition.
- The examination must confirm the existence of a lesion, injury, or condition that is consistent with the patient’s complaints and the exam findings must be documented in the chart.
- The management of the case or treatment rendered must be considered appropriate for the condition.
- The patient chart should reflect overall improvement over the course of treatment.
The best practices described here are endorsed by many health care organizations, regulatory agencies (e.g., NCQA) and state authorities. Want more information on record keeping or other best practices for integrative healthcare providers? Search “best practices” on this site to read more in this series of articles.