HSWT

SOAP: TL;DR

One of the things that has driven many of us into informatics was how terrible it is to enter information into a patient's chart. There are lots of reasons for that, but this recurring segment is going to be about formatting and presentation. This is obviously a long discussion, but it's one that needs to happen soon before all of the crap notes we use now are forever put into HIE and can never be changed again.

So, I'm going to start with order the assessment and plan. And section titles. Oh, I should mention this is for general medical notes, probably including pediatric notes, internal medicine, possibly ICU notes...to some degree. This is certainly just brainstorming on my part, so please let me know if you have any suggestions, recommendations, thoughts, or just want to call me an idiot.

Step 1: Let's not be so judgmental and paternalistic. Let's change that chief complaint to chief concern. And that can go first, I don't mind.

Step 2: So whether or not you put the Chief Concern at the top, next needs to come the the Assessment and Plan. This is the only section that most people read anyway. So instead of having to scroll through all of the extra junk that most people include, put it visibly at the top, save everyone the time and energy, and write it well.

Step 3: Format of A&P. This one is tough, and I'm freely open to debate. I think probably a kind of generalized assessment of the patient is appropriate, 2-4 lines maximum that summarizes the patient.

Step 4: More formatting. Problem based or systems based. In the ICU this one is pretty easy, and is already generally agreed that systems based is appropriate. For a child with an asthma exacerbation it seems a little overkill to do system based, although I think it would still work, you would just have one system. For many adults, more and more, they have 12 problems, 25 medications, and all of their organs are failing. Listing every problem individually makes less sense than listing as organ systems. In my example note to the right, I've listed what I consider to be a reasonable grouping of systems (yes, I know how many specialists I'm going to piss off with this).

Step 5: After the systems themselves, list the diagnoses. I think this should also include useful scores and information about the diagnoses after each one. Again, open to discussion, because certainly Oncologists include lots of receptor/mutation information about each cancer that I never pay attention to, so how detailed it needs to be is probably up to the specific practioner. We will also have to agree (or not, this is not absolutely necessary) on what diagnoses go in which system. Is Vit D Deficiency and osteoporosis two separate diagnoses? Technically yes. But we often treat them with the same medications, and tend to think of them as the same problem. So, is is musculoskeletal or an endocrine problem? Again, not something that needs a definitive answer, but something to consider. The one that may be more important is something like chest pain. As that's not a system based diagnosis, does it go in cardiovascular? What if it's almost certainly a PE? Do you put it in both?

Step 6: Thoughts. Record your thinking about things. This is especially important while working up a new problem that's not been completely elucidated. Or if you're treating a patient in a non-traditional way. Now, as I've been trying to play with different types of formats for this, I'm not sure that after each section is the best place for this. If you do it after every section, then it becomes too long. Perhaps this should be combined with the next section?

Step 7: Specific treatment. Again, this is one that I think can be personalized. Some people like specific meds with dosages, some with just the medication, some with the class of medication. I think any of them are fine. As long as it's clear what you're doing. (besides in a well done EHR, you should just be able to lookup the medications that the patient is receiving).

Step 8: Things I've forgotten. There's a bunch of them, I'm sure. Like, where does PT/OT/ST goes in the MS/Rehab section? What if it's for a stroke? There are going to be lots of these, none of which will be answered sufficiently for lots of physicians (at least if my assessment of how flexible physicians are is accurate). But I still think we need to start. If we don't decide, someone else is going to decide for us.

Step 9: Yeah, I still don't like it either. It needs to be short, clean, readable, but still hold all of the information required. It's a challenge for sure, and we'll probably need to use information and knowledge from people that have been doing this for years (read, everyone who has made successful, readable web pages). I'll update it as I think I have improvements, but I'm also open to all suggestions.