A return to the problem-oriented SOAP note

CMS is changing note requirements, among other changes. Bob Doherty has a wonderful summary: “Medicare’s historic proposal to change how it pays physicians.”

As always, we really will have a difficult time sorting out the unintended consequences of these changes, but they certainly seem like a move in the proper direction. To me the most important change is a focus on notes: “Allowing medical decision making to be the basis for documentation, requiring physicians to only document changed information for established patients and to sign-off on basic information documented by practice staff.”

Hopefully, we will begin to teach and expect Larry Weed’s SOAP notes as taught in the early 70s. Here is an example of a totally fictional hospital note that I might have written in 1975.

#1 Hyperglycemia

S – No complaints.

O – Glucose lowered from a high of 800 to 150. Patient had 2 hypoglycemic episodes. Anion gap remains normal (I might include the BMP here). Normal phosphate.

A – Glucose easily lowered. Patient had hyperosmolar nonketotic syndrome. Potassium and phosphate remain normal.

P – Switch from IV insulin to scheduled long-acting insulin and short-acting with meals. Will reinstitute his prescribed 25 u glargine daily with 5 u regular with each meal.

#2 Confusion

S – No longer confused.

O – Alert and oriented x 3.

A – Problem resolved – likely secondary to glucose lowering.

P – Continue present management.

#3 Low BMI

S – Patient states that he became thin 6 years ago when diabetes diagnosed. He gives a history of pancreatitis at least 2 times and what sounds like a partial Whipple. He also describes steatorrhea for 6 years.

O – BMI 13

A – Given the history of pancreatitis, brittle diabetes and steatorrhea, we suspect that the patient does not have type 2 diabetes mellitus, but rather type 3c – pancreatic diabetes. This also explains the previous history of metformin not helping his glucose control.

P – This changes our goals – we are not seeking tight control. We will start pancreatic enzymes as this might help his steatorrhea.

What do you think of this style note? I was trained to write notes like this. They are problem-oriented and reveal our thought process. I can only hope we return to this style.

Robert Centor is an internal medicine physician who blogs at DB’s Medical Rants.