SOAP Note Documentation Review PDF

SOAP Note Documentation Review Lauren Clemmons, DO, FACOFP [email protected] Objectives Describe the major components of a SOAP Note and the subcategories within each major category. Identify which elements to document in each category of a SOAP note (S, O, A, and P). Demonstra...

SOAP Note Documentation Review Lauren Clemmons, DO, FACOFP [email protected] Objectives Describe the major components of a SOAP Note and the subcategories within each major category. Identify which elements to document in each category of a SOAP note (S, O, A, and P). Demonstrate how and when to document pertinent positives and pertinent negatives. Demonstrate how to document completed studies vs. pending studies. Demonstrate how to document procedures, including OMT. Demonstrate the NBOME standards for SOAP note documentation. Documentation Medical-Legal Document Not documented = Not done Way of communicating to all health care professionals about the patient Helps you follow patient over time Ensures proper compensation 3 Are All SOAP Notes the Same? Full H&P Focused SOAP Note Clinic Hospital OB-GYN Note Post-op Note Full History and Physical (H&P) New Patient in Clinic Hospital Admission Annual Physical More thorough Full exam Full ROS More detailed history Allows subsequent encounters/documentation to be shorter/faster 5 The SOAP Note Focused Tailored to presenting problem Contains pertinent info only What questions do I need to ask? (SUBJECTIVE) What physical exam do I do? (OBJECTIVE) What do I think is going on? (ASSESSMENT) What am I going to do about it? (PLAN) NBOME style SOAP notes include all components of a full H&P, but they can be focused on the chief complaint. A hospital or clinic SOAP note will generally just state that the PMFSH has been reviewed. -You will learn how to write these 3rd year! 6 e-SOAP Notes Record clinical findings, exercise clinical problem-solving skills, and formulate a differential diagnosis and a diagnostic and treatment plan. Use either a narrative or a “bullet” or “laundry list” style Document in English With the exception of the vital signs provided, under no circumstances should candidates document results of physical examination maneuvers or techniques that were not performed or a medical history that was not elicited. Such documentation will be considered irregular conduct and will be thoroughly investigated and dealt with according to NBOME’s policies and procedures All e-SOAP Notes should be completed to stand alone as the only documentation for that encounter, as information on scrap paper or the doorway information sheet will not be considered as part of the required documentation.  e-SOAP Note We generally advise candidates to avoid or limit abbreviations in medical documentation because of the lack of standardization and the potential for medical error. If a candidate desires to use abbreviations, we advise using only those that are considered common and would be easily recognized by the osteopathic physician examiners scoring the e-SOAP Notes. The use of uncommon, obscure, confusing, or idiosyncratic abbreviations risks misinterpretation by the physician examiner, which could negatively impact the score on the Note. Common English language or medical abbreviations are included in the “Common Abbreviations List,” which will be available at each e-SOAP Note desk outside the examination room Common Abbreviations List Official “Do Not Use” List e-SOAP Notes Use the following model in constructing your Note: S = Subjective findings List patient input regarding the problem(s), medical history, etc. O = Objective findings List data from your physical examination, lab or imaging studies, etc. A = Assessment Provide your impression of the diagnosis, listing at least three possible etiologies for the patient problem, symptom, or concern, ranked in order of likelihood for the given case. For wellness visits, list at least three problems or risk factors. P = Plan Provide your plan for preliminary workup and treatment (indicated diagnostic investigations, other history and physical exam data you would gather, and therapeutic interventions). Specific drug dosages are generally not required, but be as specific as possible when referring to diagnostic tests. Documentation skills Essentially: Can you write a good SOAP note? Does the info in the “S” and “O” lead the reader to The conclusion (diagnosis) that you state in “A” And does the plan in “P” make sense for “A”? Subjective (S) What the patient tells you. Begins with: ID First and Last Name Age (NOT date of birth) CC in patient’s own words if possible (use quotes) HPI (OPPQRRST-A) Paragraph format is best. Complete sentences not required. Accepted abbreviations only. Don’t put OPPQRRSTA in your note!!!! Mr. John Jones is a 56-year-old man who presents to the ED c/o “the worst headache I’ve ever had.” The pain started 2 hours ago, is 9/10 and is “stabbing” and constant. Movement makes it even worse. Nothing makes it better. Whole head. Doesn’t radiate. Sudden onset at severe level. Associated with nausea and blurred vision. Nothing like this before. 13 Subjective Continues with: Past Medical History (PMH) Significant medical problems Medications: Name, dose, route, frequency Rx, OTC, Vitamins, Supplements Allergies Allergy and reaction PMH Surgical History HTN x 10 years, COPD x 5 years Meds: Spiriva 1 puff daily, lisinopril 20mg PO daily Hospitalizations/ER visits Allergies: Penicillin causes rash appendectomy, 1992 No hospitalizations Do not put “SMASH” in your note! Subjective Continues with: Family History Focused vs. complete Social History Tobacco, Alcohol, Drugs – Type, how much, how often Others relevant to CC – occupation, exercise, diet Do not state that a category is: N/A, none, unremarkable… FH Dad died of MI at 76. Mom,78, has HTN. 2 sisters, both healthy. 1 son, 28, has HTN. SH 1 ppd for past 25 years, no ETOH, married, no illicit drug use. Subjective Continues with: Review of Systems (ROS) Ask about pertinent systems Abdominal Pain: General, GI, GU, CV, Resp Arm Pain: General, MSK, Neuro Chest Pain: General, CV, Resp, GI No certain number of systems or questions required. Can include positives/main system in HPI BUT… You MUST have a separate ROS section that refers reader to the HPI ROS: As stated in HPI and denies fever, chills, vomiting, syncope, weakness or heartburn Use words like “denies,” “admits,” or “endorses” You may also document You can also use (+) or (-) ROS by system, but it is Do NOT say “ROS negative” not required for OSCEs. List out the symptoms that you asked! Example: General: Denies fevers, ROS: (+) nausea, vomiting, and diarrhea. (-) chills, fever, weight loss, blood in stool chills, and weight loss ROS: Endorses cough, wheezing, chest pain with deep breaths, and nausea. Denies GI: Admits nausea, headaches, fever, chills, weight change, or shortness or breath. vomiting, and diarrhea. Denies blood in the stool. 16 Subjective (Summary Slide) Candidates are instructed to document significant findings from the patient’s history in the “Subjective” portion. Open with Name, Age, Gender and chief complaint in patient’s own words: John Smith is a 53-yo man who presents with cc of “my chest hurts.” Follow with the OPPQRRSTA. You do NOT have to have complete sentences: John Smith is a 53-yo man who presents with cc of “my chest hurts” x 45 min. Feels like “tightness”. 6/10 pain. Radiates to left arm and jaw. Onset while walking upstairs. Slightly better with rest. Feels like last MI. Associated with nausea, dyspnea and diaphoresis. Next list key findings from PMH, FH, SH and ROS: PMH: HTN, MI in 2015 Meds: ASA 81 mg PO daily, lisinopril 20 mg PO daily, metoprolol 50 mg PO daily NKDA FH: Dad and 2 brothers with CAD SH: 30 pack years, 1-2 beers per month, no illicit drug use ROS: As stated in HPI and denies fever, chills, vomiting, syncope, weakness or heartburn Objective (O) What is Observed or Measured Descriptions/Findings NOT, conclusions or diagnoses Physical Exam Lab results EKG results PFTs Radiology reports Only document what was done 18  Objective Go Head to Toe and Include: Vital Signs General Appearance Lying on table, moaning Pertinent positives and negatives Don’t use “good,” “normal,” etc. Heart: RRR, no murmur (no gallop, no rub) Lungs: CTA (no wheezing, no crackles) 19 Body Areas/Organ Systems Constitutional Eyes Ears, nose, mouth, throat Neck Cardiovascular Respiratory Chest Gastrointestinal Genitourinary Musculoskeletal Integumentary Neurological Psychiatric Endocrinology Hematologic/lymphatic Allergy/immunologic 20 Osteopathic Findings Your entire exam is osteopathic! Should be incorporated throughout the exam List with the relevant system Cranial – head Chapman’s points – with the appropriate organ system TART changes – with MSK Anterior fibular head L5 FSRRR Left on left sacral torsion Acute vs. Chronic Somatic Dysfunction 22  Objective Other studies – Listed below the physical exam Labs CBC: WBC 10.3, Hg 13.6, Plt 223 Imaging – Use the wording on the official report when available Radiopaedia.org CXR: Heart is normal size. No hilar lymphadenopathy. No acute disease noted. EKG Regular rhythm, rate 65, no ST changes  Objective (Summary Slide) Physical examination findings and any other key objective findings are recorded in the “Objective” portion. Candidates should try to be as specific as possible when documenting physical findings, avoiding the word “normal.” Start with vital signs: BP 120/72, HR 92, RR 14, Temp 98.6 Next describe the patient’s general appearance. It can be short and to the point: Alert. OR Appears comfortable. OR Writhing in pain. OR Appears anxious. Next document your most important exam findings. If worried about time, I would document the most important system first. For chest pain, document heart and lungs. For knee pain, document knee exam. Look at the list of acceptable abbreviations and think about how to say as much as possible using the fewest characters. For example, Heart: RRR and Lungs: CTA says quite a bit! Review common documentation. Examples below. “Intact” is usually used for Neuro exam: CN II-XII intact, Vibratory sensation intact. Strength is out of 5. Full strength = 5/5. “Normal” reflexes or pulses are usually called “2+.” Don’t document anything you didn’t do. Only put “A & O x 3” if you really checked person, place and time. Assessment (A) What you think or know is wrong with the patient Diagnosis must be supported by the S and O! Can be: working diagnosis problem list reason for visit differential diagnosis (NBOME) Refer back to the Assessment and Plan lecture for full discussion of Assessment. Today we will focus on NBOME/OSCE Style Assessment documentation 25 Assessment- differential diagnosis (NBOME) All OSCE SOAP Notes C3DO Update Assessment- differential diagnosis (NBOME) Example: Patient presents with fatigue. Has dark stools and craves ice. Has conjunctival pallor and mild tachycardia on exam. Assessment 1. Anemia (plausible diagnosis) Please note: 2. and 3. only have to be 2. Depression (diagnostic possibility for presenting problem (fatigue)) possibilities for the 3. Fibromyalgia (diagnostic possibility for presenting problem (fatigue)) presenting problem. Assessment 1. Iron deficiency anemia (plausible diagnosis) 2. B12 deficiency anemia (diagnostic possibility for presenting problem (fatigue)) 3. Anemia of chronic disease (diagnostic possibility for presenting problem (fatigue)) Remember: If you perform OMT during the encounter, you MUST include Somatic Dysfunction as a diagnosis!! Assessment for Somatic Dysfunction Will ALWAYS have at least 2 diagnoses One directly for the chief complaint (think about how an allopathic physician would diagnose the complaint) One or more areas of somatic dysfunction Documenting OMT Diagnosis = Somatic dysfunction of… You have 10 choices Billing and Coding ICD-10 Codes Somatic Dysfunction (SD) Head SD (M99.00) Cervical SD (M99.01) Thoracic SD (M99.02) Lumbar SD (M99.03) Sacrum SD (M99.04) Pelvic SD (M99.05) Lower Extremity SD (M99.06) Upper Extremity SD (M99.07) Rib SD (M99.08) Abdomen SD and Other SD (M99.09) 31 32 Documenting Somatic Dysfunction Somatic dysfunction of the sacrum OR Somatic dysfunction of the sacrum with R/R sacral torsion  Plan (P) What are you going to do? Testing Ultrasound of Abdomen Hg, Plt, Na, Glucose Treatment Medications – name or drug class OMT – technique style and location (MFR to thoracic spine) Include procedure note Education/Health Promotion Tobacco/drug/alcohol cessation, diet, exercise, counseling on after-effects of OMT Disposition Are they going to/staying in the hospital? If they are going home, when should they come back? Are they being referred to a specialist? Follow-up in clinic in 5-7 days 34 OMT Procedure Note Place in the Plan portion of the SOAP note for NBOME Usually documented separately in other EMRs OMT is a procedure Physical findings and resultant SD (in your objective/assessment) Patient’s verbal consent OMT performed Patient’s response to treatment OMT Procedure Note Template Risks, benefits, alternatives to OMT discussed Obtained verbal consent from patient Performed [insert techniques and body region here] You can just name technique styles – MET, MFR, Counterstrain… If you list specific technique names, you must list every technique performed Pt tolerated treatment well and reported pain is better/worse/ same Reassessment of TART findings Educated patient on potential post-treatment soreness and encouraged increased fluids 36 OMT Sample Note Risks, benefits, alternatives to OMT discussed Obtained verbal consent from patient Performed soft tissue technique and post-isometric MET to upper thoracic spine (T1-T5) Pt tolerated treatment well and reported pain is better Resolution of right rotation at T1-T5 after treatment OR T1-T5 rotation improved after treatment OR no change in rotation of T1-T5 after treatment Educated pt on potential post-treatment soreness and encouraged increased fluids Follow-Up OMT is not done in isolation Follow-up is for the somatic dysfunction, not OMT 38 Procedure Note PROCEDURE: Right knee joint steroid injection. PREOPERATIVE DIAGNOSIS: Osteoarthritis of the right knee. POSTOPERATIVE DIAGNOSIS: Osteoarthritis of the right knee. PROCEDURE: The patient was apprised of the risks and the benefits of the procedure and consented. The patient’s right knee was sterilely prepped with Betadine. A 4 mg of dexamethasone was drawn up into a 5 mL syringe with a 3 mL of 1% lidocaine. The patient was injected with a 1.5-inch 25-gauge needle at the medial aspect of his right flexed knee. There were no complications. The patient tolerated the procedure well. There was minimal bleeding. The patient was instructed to ice his knee upon leaving clinic and refrain from overuse over the next 3 days. The patient was instructed to go to the emergency room with any usual pain, swelling, or redness occurred in the injected area. The patient was given a follow-up appointment to evaluate response to the injection to his increased range of motion and reduction of pain. http://www.medicaltranscriptionsamples.com/knee-injection-1/ Plan Here are some examples: Working Dx: Acute MI EKG Troponin, CKMB ASA now with morphine prn pain Cardiology consult Admit to cardiac floor Working Dx: Acid Reflux PPI Decrease caffeine and spicy food intake Raise head of bed F/u in 2 weeks Working Dx: OA of right knee X-Ray right knee Tylenol prn pain Trial of OMT (Specify what if possible) Weight loss F/u in 1 month  Plan (Summary Slide) For the “Plan” component, candidates should note the workup or treatment they would propose for the patient, including questions or physical exam maneuvers that they inadvertently did not ask or perform, but would plan to do if time allowed. In most cases, specific drugs or drug dosages are not required, but candidates should try to be as specific as possible when referring to diagnostic tests (e.g., serum electrolytes, BUN, creatinine, and glucose as opposed to “blood tests,” “SMA7,” or “chemistry panel”). There is no number of bullets specified for Plan. Options include, but are not limited to: Physical exam you didn’t have time for or aren’t allowed to do (pelvic exam, MMSE, etc.) Questions you didn’t have time for or forgot to ask (“Obtain full sexual history,” etc.) Medication Imaging Labs OMT Lifestyle modifications (diet change, exercise, smoking cessation) Referrals (specialist, PT, OT, etc.) Disposition (admit to hospital?) Follow-up (Reassess in 24 hours to make sure responding to treatment?) Sample SOAP Note Subjective Name: John Smith Date of Visit: August 12, 2020 Date of Birth: March 3, 1974 Age: 46 SUBJECTIVE: Chief Complaint: “I have head congestion.” History of Present Illness: Patient reports cold symptoms for the last 10 days, which are worsening. He reports a dry cough, stuffy nose with purulent drainage, and dull frontal headaches on the right. He rates the pain 7/10. He denies fevers. Decongestants and ibuprofen help with the pain. Denies any provocative factors, no radiation of the pain. He has also been taking cough drops. Past Medical History: Hypertension Past Surgical History: None Medications: Lisinopril 10 mg PO once daily, Ibuprofen 800 mg PO TID PRN pain, OTC cough drops PRN cough Allergies: NKDA Family History: Father, 72, living, has CAD and type 2 diabetes; Mother, 70, living, had lung cancer; Sister, 42, living, has type 2 diabetes ; 2 daughters, 10 and 12, healthy Social History: Previously smoked 1 ppd cigarettes x 15 years, quit 10 years ago. No alcohol, no illicit drug use. He is a high school teacher, married, and has 2 children. 43 Subjective Review of Systems: Constitutional: Admits fatigue. Denies fever and recent weight changes. HEENT: See HPI above. Cardiovascular: Denies palpitations and chest pain. Respiratory: Non-productive cough. Denies SOB. GI: Decreased appetite. Denies nausea, vomiting, or diarrhea. GU: Denies urinary frequency and dysuria. MSK: Denies arthralgia and decreased ROM. Skin: Denies rash and pruritus. Neurological: Admits frontal headache. Denies sensory changes. Psychiatric: Denies anxiety and depression. Endocrine: Denies increased thirst. Heme/Lymph: Admits swollen cervical lymph nodes. Denies bruising. 44 Objective Physical Exam: Vital Signs: BP: 130/85, HR: 90, T: 99.8°F, RR: 16, Ht: 69 inches, Wt: 160 lbs. General: Well developed, well nourished, no acute distress, sitting comfortably in a chair HEENT: Frontal and maxillary sinuses tender to palpation, right > left. Right TM dull. Edematous nasal turbinates. Throat non-erythematous. Post-nasal drainage present. Cardio: RRR. No murmurs, rubs, or gallops. No edema. Capillary refill